Initial Management Of Patients Research Articles

Aortic remodelling based on false lumen communications in patients undergoing acute type I dissection repair with AMDS hybrid prosthesis: a substudy of the DARTS trial.

The Dissected Aorta Repair Through Stent Implantation trial demonstrated positive proximal aortic remodelling following aortic dissection repair with the AMDS Hybrid Prosthesis. In this study, we look to identify predictors of aortic remodelling following aortic dissection repair with AMDS including whether communications between branch vessels and the false lumen predict aortic growth. The Dissected Aorta Repair Through Stent Implantation trial included patients who underwent Acute DeBakey type I aortic dissection repair with the AMDS from March 2017-January 2019. Anatomic measurements were collected from original computerized tomography scans. Measurements were taken at zones 2, 3, 6, and 9. Patients were grouped based on the number of false lumen communications with the supra-aortic branch vessels or visceral branch vessels. Forty-seven patients were included in the original Dissected Aorta Repair Through Stent Implantation trial. Patients with false lumen communications with the supra-aortic branch vessels tended to have significant growth at zone 3(p = 0.02-0.0018), while greater numbers of visceral false lumen communications tended to predict aortic growth at zones 3 (p = 0.003), 6(p = 0.017-0.0087), and 9(p = 0.0016-0.0003). Aortic remodelling following Acute DeBakey type I aortic dissection repair using the AMDS may be predicted by local false lumen communications with branch vessels. Patients undergoing Acute DeBakey type I aortic dissection repair were more likely to experience significant aortic growth in zone 3 with more head vessel communications and in zones 3, 6, and 9 with more visceral false lumen communications. Predictors of aortic remodelling may help to guide initial surgical management for aortic dissection patients.

Experiences of injured patients referred to higher levels of care after initial assessment and management at non-tertiary hospitals in Ghana

BackgroundThe experiences of trauma patients referred from Ghanaian non-tertiary hospitals for definitive care at higher levels is not well-known. Understanding the motivations of injured patients who do not attend their referral for definitive management may inform interventions to improve injury outcomes. MethodsThis study is a follow-up survey of participants of a larger study involving initial management of injured patients presenting to 8 non-tertiary hospitals in Ghana from October 2020 to March 2022. Injured patients referred to higher levels of care were surveyed by phone using a structured questionnaire and patients who could not be reached were excluded. The main outcome was referral non-attendance and differences between patients who attended the referral and those who did not were determined with chi squared tests. Variables with intergroup differences were included in a multivariable logistic regression. Open-ended survey responses were analyzed using thematic content analysis. ResultsOf 335 referred patients surveyed, 17 % did not attend the referral. Factors associated with referral non-attendance included being male (Adjusted odds ratio (AOR)=2.70, p = 0.013), sustaining a fracture (AOR=2.83, p = 0.003), and having less severe injury (AOR 2.84, p = 0.017). Primary drivers of referral non-attendance included financial problems (59 %), family influence (45 %), and lack of transportation (20 %). The majority of patients (77 %) not attending the referral sought treatment from traditional healers, citing lower cost, faster service, and a perception of equivalent outcomes. Reported facilitators of referral attendance included positive hospital staff experiences and treatment while barriers included higher hospital costs, lack of bed space, and poor interhospital communication. ConclusionsAn important proportion of injured patients in Ghana do not attend referrals for definitive management, with many seeking care from traditional healers. Our study identified possible targets for interventions aimed at maintaining the continuum of hospital-based care for injured patients in order to improve outcomes.

An evidence-based approach to diagnosing patients presenting with orbital inflammatory syndromes (An American Ophthalmological Society Thesis)

PurposeThe initial management of patients presenting with orbital inflammatory syndromes (OIS) varies – with some pursuing a diagnostic workup while others treat without any testing. The evidence behind this rationale is limited. A review of patients with orbital inflammation is performed with analysis of diagnostic testing to develop a workflow for such patients. DesignA retrospective review of patients presenting with acute orbital inflammation at a single institution from 2011 – 2020 was conducted. MethodsOrbital imaging was required for inclusion. Patients with high suspicion of neoplasm, bacterial infection, vascular malformation, or thyroid eye disease were excluded. Review of presenting clinical findings, laboratory workup, orbital imaging, and biopsy were performed. Statistical analysis was performed identifying statistically significant diagnostic and treatment maneuvers. ResultsIn total, 172 patients met inclusion criteria (66% female, mean age 46 years). The primary clinical presentation was myositis, dacryoadenitis, and infiltrative in 67, 73, and 32 patients (39.0, 43.0, 18.6%, respectively). Laboratory studies were conducted in 145 (84%) while biopsy was performed in 55 (32%). Specific orbital inflammation (SOI) was diagnosed in 29 (16.9%) with most frequent diagnoses being sarcoidosis, IgG4-related disease, inflammatory bowel disease, and systemic lupus erythematosus. The majority (147, 85.5%) was initially treated with steroids, but steroid-sparing agent use was statistically higher in patients with SOI. ConclusionsIn patients presenting with OIS, distinguishing myositis, dacryoadenitis, and infiltrative disease has workup and differential diagnosis impacts. Because SOI is relatively common, sequelae of SOI, and potential steroid-sparing therapy needs, diagnosis via an evidence-based systemic approach is critical.

Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC).

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.

Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric Versus Community Emergency Department Setting.

Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes. We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge. Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups. Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.

New Insights into First-Line Therapy in Diffuse Large B-Cell Lymphoma: Are We Improving Outcomes?

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of lymphoma, comprising heterogeneous patient subgroups with distinctive biological and clinical characteristics. The R-CHOP combination (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) has been the standard initial treatment, yielding prolonged remissions in over 60% of patients with advanced-stage disease. Several attempts to enhance the outcomes of this regimen over the last two decades have shown limited success. Various novel therapeutic approaches have recently emerged in lymphoma, demonstrating promising results. These include small molecules, novel monoclonal antibodies, antibody-drug conjugates (ADC), bispecific antibodies (BsAbs), and chimeric antigen receptor (CAR) T-cell therapy. This review explores recent advancements in therapeutic strategies for DLBCL and their potential impact on the initial management of DLBCL patients.

Acute Burn Care.

After studying this article and viewing the videos, the participant should be able to: 1. Describe the current epidemiology of burn injuries. 2. Understand burn pathophysiology and perform a wound assessment. 3. Summarize the initial emergency management of a burn patient. 4. Calculate the anticipated fluid resuscitation requirements for a burn injury, and diagnose the complications of overresuscitation. 5. Describe the diagnosis and management of inhalation injury. 6. List the goals of wound care for superficial and deep burns, and describe the closed dressing technique. 7. Perform excision of a burn wound. 8. Compare various wound closure techniques using autografts and skin substitutes. Plastic surgeons are essential members of the multidisciplinary burn team. Burn injuries remain common, and plastic surgeons have an opportunity to develop and innovate the field of acute burn care in light of workforce shortages. Burn pathophysiology is complex and dynamic, which informs the challenges encountered during the perioperative phase. Accurate burn wound assessment remains difficult, with implications for diagnosis and management. A systematic approach is required when stabilizing a major burn and/or inhalation injury with newly updated fluid resuscitation and triage guidelines. Wound care continues to evolve, with an emphasis on a closed dressing technique. For deeper burns, new surgical techniques are emerging for surgical débridement, along with improvements to traditional methods of tangential excision. Following excision, a number of established and novel techniques are available to close the wound with either autografts or skin substitutes.

Diagnosis, prognostic factors, and assessment of ALL in adults: 2024 ELN recommendations from a European expert panel

AbstractWorking groups of the European LeukemiaNet have published several important consensus guidelines. Acute lymphoblastic leukemia (ALL) has many different clinical and biological subgroups and the knowledge on disease biology and therapeutic options is increasing exponentially. The European Working Group for Adult ALL has therefore summarized the current state of the art and provided comprehensive consensus recommendations for diagnostic approaches, biologic and clinical characterization, prognostic factors, and risk stratification as well as definitions of endpoints and outcomes. Aspects of treatment, management of subgroups and specific situations, aftercare, and supportive care are covered in a separate publication. The present recommendation intends to provide guidance for the initial management of adult patients with ALL and to define principles as a basis for future collaborative research.

Approach to burn treatment in the rural emergency department.

To outline an approach to the assessment and initial management of patients with burns in the rural emergency department setting. Three mnemonics are presented that can be used for both the assessment and the initial management of patients with burns in rural settings. Current and local guidelines compiled by a plastic surgeon were reviewed to develop a systematic approach to the treatment of patients with burns. PubMed and other databases were also searched for current literature on emergency care of patients with burns. Burn injuries are a common reason for presentation to the emergency department. However, the care of patients with these injuries can vary substantially depending on geographic location, provider training, and hospital resources. Classification of burns, fluid resuscitation guidelines, dressings and wound care, indications for referral, and pain management are discussed. Using a systematic approach may help improve burn injury outcomes for patients and provide practitioners with a step-by-step framework for the management of patients with burns in rural settings.

Initial Imaging of Pregnant Patients in the Trauma Bay—Discussion and Review of Presentations at a Level-1 Trauma Centre

Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5–7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.

How Sensitive Is the Sickle Prep? Clinical Implications

Introduction The sickle cell solubility test, commonly known as “sickle prep” is a qualitative measure that relies on the property that deoxygenated hemoglobin S (HbS) is insoluble. Accordingly, blood samples drawn from individuals with circulating HbS appear cloudy when mixed with sodium hydrosulfite. 1 The sickle cell solubility test has been reported to be very sensitive (99%) and specific (99.9%) for detection of HbS. However, false negatives have been reported to occur in sickle cell disease (SCD) patients with severe anemia or high levels of hemoglobin F. 2,3 In those situations HbS levels may be very low and it remains unclear what level of HbS is required for the solubility test to be positive. To address this issue, we have examined the sickle cell solubility test in a cohort of SCD patients undergoing red cell exchange, acknowledging that in many of these patients, HbS levels fall below 15% when tested immediately after completing the exchange procedure. Methods 118 patients with sickle cell anemia were screened based on outpatient visits to the Inova Adult Sickle Center from January 1, 2023 - March 31 st, 2023. Of these, 6 patients were excluded from analysis due to lack of recent sickle cell solubility test during this period. Of the total number of patients included in the analysis (n=112), 25 (22%) underwent red cell exchange during this period. For each individual, the two most recent HbS percentages with the concurrently-determined sickle cell solubility result (positive or negative) were analyzed. We examined the data in the context of known genotype (HbSS, HbSC, HbSβ 0, HbSβ +positive). In patients undergoing red cell exchange, the most recent pre and post transfusion hemoglobin S percentage were collected. Results: 200 distinct HbS levels were collected and analyzed. Of those, 5/200 tested negative for the sickle cell solubility test, yielding an overall sensitivity rate of 98%. Of those 5 patients, 4/5 had received a red cell exchange during this period, and (1/5) had severe transfusion dependent anemia. Of those with a negative sickle cell solubility test, 4/5 patients had an SS genotype, and 1/5 had SC genotype. In patients who received red cell exchange, the sensitivity rate for the sickle cell solubility test is 84%. For all patient samples with HbS &amp;gt;15%, the sickle solubility test was 100% sensitive. However, among the 11 samples with HbS levels below 15%, 5 were sickle prep negative thereby indicating a reduced sensitivity (55%) below that threshold. Nine (9) out of the 11 samples were of patients who had undergone red cell exchange. Conclusion: The sickle cell solubility is a very sensitive measure to establish the presence of HbS, but must be interpreted with caution in those with HbS concentrations of &amp;lt;15%. Because it is readily available (typically resulted within an hour) it may be of benefit in emergency departments for patients for whom there is question about the validity of the sickle cell diagnosis. At our institution, this has been a valuable addition to the initial management of patients for whom medical records are not available and who present with apparent acute vaso-occlusive crisis. We do not propose withholding analgesia for patients with a reported history of sickle cell disease pending this test, but rather recommend its use as a confirmatory test for patients presenting with a reported history of this disease.

Initial management and survival of patients with primary metastatic bladder cancer before the immunotherapy era: a population-based study from Norway.

Before immunotherapy became part of the management of metastatic bladder cancer (mBC), systemic anti-cancer treatment comprised primarily of platinum-based chemotherapy. The objective of this study was to describe the characteristics, the initial management, overall survival (OS) and hospitalisations of patients with mBC before 2018 when immunotherapy for mBC was introduced in Norway. Material and methods: It is a nationwide population-based study of primary mBC patients (diagnosed 2008-16). Descriptive statistics were applied and stratified for four initial management options (≤150 days after BC diagnosis): chemotherapy, major local treatment (cystectomy/pelvic radiotherapy), multimodal treatment (chemotherapy and local) and no anti-cancer treatment beyond transurethral resection of bladder tumour (untreated). Group differences were evaluated by Chi-square and Kruskal-Wallis test; OS was estimated with Kaplan-Meier. Results: Of the 305 patients included, 76 (25%) patients had chemotherapy, 46 (15%) patients had major local treatment, 21 (7%) patients had multimodal treatment and 162 (53%) patients were untreated. Median OS ranged from 2.3 months (untreated) to 9.8 months (chemotherapy). Patients who received treatment had a higher rate of hospitalisation, with a median stay of three to four times that of untreated patients. Conclusion: Before immunotherapy, more than 50% of patients with primary mBC did not receive any initial anti-cancer therapy and had a poor survival. Patients treated with chemotherapy had inferior median OS compared to those treated with comparable systemic strategies in contemporary trials. Our results provide a basis for future research on treatment and survival after the introduction of immunotherapy for mBC, aiming to improve the care and outcome of patients with mBC.

In-hospital prognosis of recreational drug use in patients with acute ST-elevation myocardial infarction: insights from the ADDICT-ICCU study

Abstract Background Although recreational drug use may induce ST-elevated myocardial infarction (STEMI), its prevalence in patients hospitalized in intensive cardiac care units (ICCUs), as well as its short-term cardiovascular consequences, remains unknown. Purpose To assess the prevalence of recreational drug use and its prognosis for in-hospital major adverse cardiac events (MACEs) in patients with STEMI. Methods From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1575 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for STEMI. The following recreational drugs were detected within two hours after admission to the ICCU: i) tetrahydrocannabinol including cannabis and marijuana; ii) cocaine; iii) amphetamines; iv) MDMA; and v) heroin and other opioids. Administration of morphine for pain sedation during the initial management of patients was recorded, and their urine test for opioids was considered negative. The primary endpoint was MACEs defined by death, resuscitated cardiac arrest, or cardiogenic shock. Results Among the 325 patients with STEMI (age 62±13 years, 79% men), 41 (12.6%) had a positive test (cannabis: 88%, opioids: 37%, cocaine: 10%, MDMA: 5%). The prevalence of drug use increased to 34% in patients under 50 years of age. Recreational drug users were more frequently men (93% vs. 77%, p=0.02), younger (50±12 years vs. 63±13 years, p&amp;lt;0.001), and more active smokers (78% vs. 34%, p&amp;lt;0.001). Multiple drug use was reported in 16 cases (39%). Of the 41 patients with recreational drug use, 22 (54%) self-reported the use of recreational drugs on admission. During hospitalization, 17 MACEs occurred (5.2%), including 6 deaths (1.8%), 10 cardiogenic shocks (3.1%), and 7 cardiac arrest events (2.2%). Ventricular arrhythmia was more frequent in recreational drug users (9.8% vs. 1.4%, p=0.01). Use of recreational drugs was associated with more MACEs after adjustment for comorbidities (OR=13.6; 95%CI: 3.6-57.3). Conclusion In patients with STEMI, recreational drug use is prevalent, especially in patients under 50 years of age, and is independently associated with an increase of MACEs with more ventricular arrhythmia.Prevalence of recreational drug usePrognosis of recreational drug use

Abstract 15274: STEMI as Initial Manifestation of Essential Thrombocythemia

Background: Essential thrombocythemia (ET) is a myeloproliferative neoplasm of myeloid cell expansion, mainly excessive platelet production, associated with thrombotic complications. Myocardial infarction (MI) in the setting of ET can result from thrombosis in the absence of coronary atherosclerosis. Here we present a case of ST elevation MI in the setting of previously undiagnosed ET. Case Report: A 59-year-old male with hypertension presented to the ED with left upper extremity weakness which started upon waking. On exam, he was in acute distress and diaphoretic. EKG revealed sinus rhythm with ST elevation in II, III, aVF, V5, and V6 suggesting inferolateral STEMI (Figure 1A). Labs were notable for Hgb 8.5g/dL, white blood cell count 33k/μL, and platelets 1.9million/μL. Decision Making: He was loaded with aspirin and clopidogrel (dual antiplatelet therapy-DAPT) and taken for coronary angiogram which revealed 80-90% thrombotic occlusion of the left circumflex artery (Figure 1b). Thrombectomy was performed and a drug-eluting stent was placed. A bone marrow biopsy showed JAK2 positive ET with myelofibrosis. He was immediately started on hydroxyurea. Platelets remained elevated, thus pegylated IFN alpha-2a was started which normalized platelet count. He remained on DAPT through discharge with no recurrent ischemic events or in-stent thrombosis during the 45-day hospitalization post stent placement. Conclusion: Patients with ET are at high risk for arterial thrombosis regardless of the presence of traditional atherosclerotic risk factors. High-risk patients, which includes those age over 60 with JAK2 mutation or history of arterial thrombosis, should be treated prophylactically with aspirin and hydroxyurea for cytoreduction. MI may be the first clinical manifestation of ET, even in patients without atherosclerotic risk factors. Initial management in patients with ET presenting with STEMI includes PCI with DAPT and early cytoreductive therapy.

Clinical Evaluation Findings in Patients Diagnosed With Deltoid Ligament Ankle Sprains: A Report From the Athletic Training Practice-Based Research Network

Objective: To describe clinical presentation and initial management of patients with deltoid ligament ankle sprains. Design: Retrospective. Setting: Practice-based research network. Participants: Athletic trainers (n = 133) from 52 clinics in 19 states. Independent Variable: Deltoid sprains (October 2009–April 2020). Main Outcome Measurements: Clinical findings (e.g., sport, mechanism of injury, severity, range of motion, tests) and initial management. Results: Deltoid sprains (n = 105) were diagnosed within 3.2 ± 4.1 days of injury, mostly in male secondary school athletes (n = 62/105, 59.0%). Common sports were football (n = 29/94, 30.9%) and basketball (n = 28/94, 29.8%). Common mechanism of injuries were twisting (n = 35/94, 37.2%) and contact (n = 28/94, 29.8%). Sprains were mostly mild (n = 59/94, 62.7%) with mild or no edema (n = 85/96, 85.5%) and effusion (n = 90/96, 93.4%). Active (n = 49/96, 51.0%) and passive range of motion (n = 54/96, 56.3%) were mostly normal, and a median of four (interquartile range = 2–5) tests were used, mostly anterior drawer (n = 74/105, 70.5%) and talar tilt-eversion (n = 74/105, 70.5%). Management involved removal from participation (n = 48/94, 51.1%), treatment by athletic trainers (n = 22/40, 55.0%), and referral to physicians (n = 16/40, 40.0%). Conclusions: Deltoid sprains mostly occurred in males playing football or basketball and were caused by twisting with minimal effusion, edema, and range of motion loss. Given the infrequency of deltoid sprains and difficulty diagnosing them, thorough clinical evaluation is necessary for treatment decisions.

Pediatric Neuroemergency

The goal of initial management of any pediatric emergency patient is to rapidly assess and resuscitate the condition and provide radical therapeutic intervention while determining treatment priorities. While resuscitation is performed safely and reliably, the patient's condition should be reevaluated on an ongoing basis to determine the efficacy of the treatment. This systematic and logical approach is necessary. If the physician is unfamiliar with the examination of infants, it is most ideal to request pediatrician prior to transport, and to collaborate in the evaluation of the pediatric patient's condition and the securing of intravenous routes. In case of traumatic patient, it is advisable to notify the relevant departments in advance, such as the transfusion department and operating room. The patient's age and weight should be confirmed and accommodated. The most commonly observed symptoms in the initial treatment of children are seizures and disturbance of consciousness. Since children are particularly prone to seizures and since they can appear as a symptom of various diseases, it is necessary to differentiate the primary disease. The severity of the disturbance of consciousness depends on the types and duration of the seizures and the degree of status epilepticus making them highly urgent. Collaborate with the pediatrician because of the wide variety of differential diseases. The response to seizures and recognition of child abuse will be summarized at the end of this section.

Acute heart failure: current pharmacological treatment and perspectives.

Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.

Tatalaksana Awal Pasien Gagal Jantung Akut Akibat Penyakit Jantung Koroner di Ruang Emergency Pelayanan Jantung Terpadu Rumah Sakit Umum Pusat Sanglah

ABSTRACT&#x0D; Acute heart failure is a clinical syndrome with a complex of symptoms that is typical shortness of breath at rest or during activity. Acute heart failure is mostly caused by coronary heart disease. Coronary heart disease is a heart failure disease with narrowed coronary arteries can be caused by the buildup of a layer of fat on the walls of the coronary arteries. The purpose of this study was to determine the initial management of patients with acute heart failure due to coronary heart disease in the Integrated Heart Service Emergency Room, Sanglah Hospital. This study is a descriptive study using a cross sectional research method on a sample of 43 people who came to the PJT Emergency Room at Sanglah Hospital with a diagnosis of acute heart failure due to coronary heart disease in 2019-2020. The data that has been obtained were then analyzed using SPSS version 24. The results showed that most of the patients 30 sample (69.77%) were male compared to women, there were 13 sample (30.23%). The majority of patients with acute heart failure due to coronary heart disease come to the Emergency Room with complaints of shortness of breath. Initial treatment given in the Emergency Room included intravenous diuretic Furosemide with a dose range of 20-80 mg/IV (93.02%), Beta blockers (2.35%), Nitroglycerin (13.95%), Digoxin (13.95%), and Dobutamine (30.23%). Most of the patients in this study were given Furosemide as an initial treatment according to the PERKI 2020 guidelines which suggest the administration of Furosemide as a treatment for fluid congestion in acute heart failure. Some patients require inotropic support such as Dobutamine which is adjusted according to individual clinical criteria. Supporting examinations were carried out on all study samples (100%) including electrocardiogram (ECG) and chest X-ray examinations.&#x0D; Keywords: Acute heart failure, Coronary heart disease, Initial management&#x0D;

Identifying High-Risk Patients With Nonalcoholic Fatty Liver Disease: An Opportunity for Intervention Within the Primary Care Setting.

Patients with metabolic syndrome (MetS) are likely to have nonalcoholic fatty liver disease (NAFLD), which can progress to advanced fibrosis. Early recognition of those at highest risk may ameliorate outcomes. Noninvasive liver fibrosis assessment through validated scoring systems such as the fibrosis-4 (FIB-4) index is helpful to identify these high-risk patients, with the process ideally beginning in the primary care setting. The primary objective of this study was to determine rates of disease recognition and initial management of patients with NAFLD and advanced fibrosis in a diverse primary care setting. The secondary objective was to define demographic and clinical predictors of NAFLD identification and management in this population. Medical charts from patients seen at three university-based primary care practices in New York City from January 2016 to December 2019 were reviewed. Inclusion criteria consisted of: age 18 years and above, persistent alanine transaminase (ALT) elevation (2 values ≥40IU/mL ≥6mo apart), and body mass index ≥30kg/m 2 . Patients with viral hepatitis or alcohol misuse were excluded. Patients were defined as likely having NAFLD if they met 2 of the following criteria indicating MetS: systolic blood pressure >135mmHg or diastolic blood pressure >85mmHg or active treatment for hypertension; high-density lipoprotein <40g/dL; triglycerides >150mg/dL or active treatment for hyperlipidemia; or hemoglobin A1c ≥5.7% or active treatment for insulin resistance. The primary study endpoints were the frequency of providers' recognition of NAFLD and referral to specialist and/or for imaging based on visit diagnosis codes or chart documentation. The secondary endpoints were frequency of detecting those with NAFLD and advanced fibrosis utilizing previously defined FIB-4 index cutoffs as well as predictors of disease recognition and management. Analysis was completed using descriptive statistics and logistical regression modeling. A total of 295 patients were identified as having persistently elevated ALT, a body mass index ≥30kg/m 2 , and MetS consistent with likely NAFLD diagnosis. In patients meeting these criteria, ALT elevation was documented by primary care providers in 129 patients (43.7%), NAFLD was noted in chart documentation in 76 patients (25.8%), and a NAFLD ICD-10 diagnosis was assigned to 7 patients (2.4%). 50 patients (16.9%) were referred for ultrasound. Among 51 patients (17.2%) at high risk for advanced fibrosis based on FIB-4 >3.25, 23 patients (45.1%) had NAFLD recognized by their provider and 3 (5.9%) were referred to a specialist. On logistic regression, female gender, dyslipidemia, and private insurance were predictors of disease identification by the primary care physician. ALT elevation and NAFLD are under recognized among patients with MetS in the primary care setting. Importantly, while 17.2% of patients with likely NAFLD in our cohort were high risk for advanced fibrosis, less than half of this group had a NAFLD diagnosis recognized by their primary care provider and only three were referred to a liver specialist. Further investigation of disease recognition and management algorithms in the primary care setting are necessary to enhance NAFLD detection, implement clinical care pathways, and reduce disease progression and complications.

KS03.6.A HIGH RATE OF MULTIFOCAL RELAPSE AND SUBSEQUENT POOR PROGRESSION-FREE SURVIVAL POST SALVAGE RADIATION THERAPY FOR WHO GRADE 2-3 MENINGIOMA MANAGED WITH INITIAL SURGERY ALONE

Abstract BACKGROUND Optimal initial management for patients with localised high risk meningioma remains uncertain with long natural history disease promoting the option of delaying adjuvant radiation therapy until relapse. This study assessed patterns of relapse and survival in a cohort of patients with high-risk meningioma managed with initial surgical therapy alone. MATERIAL AND METHODS Consecutive patients with meningioma referred for radiation therapy (IMRT) between January 2008-December 2021 were entered into an ethics approved database managed by the Neuro-oncology MDT. Categorisation and subsequent management plans were based by grade on WHO2007-2016 classification. Immediate or delayed referral pathway for IMRT was individualised by neurosurgical team. At time of subsequent referral for IMRT at relapse patients had tumour site / volume determined by MRI and Dotatate PET. Tumour volume, site of relapse in relation to initial cavity and number of recurrent foci of disease were recorded. For patients subsequently receiving IMRT an integrated-boost, generally 60Gy/54Gy, was used. Primary endpoints were site of relapse in relation to initial surgical cavity, number of foci, and median time from initial surgery. Secondary endpoints were median progression-free(mRFS)/overall survival(mOS) calculated from start salvage IMRT compared to cohort of intercurrent patients managed at initial diagnosis. RESULTS One hundred and five patients with meningioma were referred, with median follow-up for survivors of 3.6yrs (q1-3:1.5-7.7yrs). Median age was 59.2yrs; 59% had convexity meningioma; WHO2016 grade was G3 in 21%; Atypical(G2) in 66% and G1/no biopsy in 9% of patients. Twenty-two patients have subsequently relapsed post IMRT; with sixteen deceased for 8yrPFS and 8yrOS of 63.5% and 73.5% respectively. Forty-nine(46%) of patients were referred for IMRT at relapse, of which 39% had repeat resection prior to IMRT referral; and 14% were WHO2016 G3 at most recent resection. Based on MRI/Dotatate 61% had more than one focus of tumour around initial surgical cavity. Subsequent to salvage IMRT, fifteen of the 49 patients have had further relapse and eleven are deceased. Patients managed at relapse had worse PFS with 55.1% 8yrPFS vs 78.0% 8yrPFS (p=0.03); however equivalent OS with 68.8% 8yrOS vs 79.4% 8yrOS (p=0.62). CONCLUSION Patients with G2/3 meningioma managed with surgery alone upfront more often had relapses that were multifocal that were not managed with further salvage surgery. The subsequent progression-free survival was poor with a high rate of subsequent relapse post salvage IMRT, especially when compared to patients managed with IMRT at time of initial diagnosis.