Initial Presenting Symptom Research Articles

Acute myocardial infarction as the initial presentation of behcet's syndrome

Behcet's disease (BD) is clinically characterized by recurrent oral and genital ulcers and ocular symptoms. However, systemic manifestations involving the lungs, gastrointestinal tract, kidneys, and heart are well known. Acute myocardial infarction (MI) is a rare manifestation of Behcet's syndrome and usually results from coronary arteries vasculitis, leading to aneurysms. More uncommon is the occurrence of acute MI as the initial presenting symptom. Hereby, we report a case of a young male who presented with acute anterior wall MI sans any other conventional risk factors with a normal angiogram. And 3 years later, he was diagnosed with BD.

Renal Calculi as Initial Presenting Symptom of Glycogen Storage Disease (Type 1 A) in Early Infancy

AbstractGlycogen storage diseases are a group of heterogeneous metabolic disorders that result from a defect in enzymatic pathway of either glycogen synthesis or glycogen degradation. Here we are reporting a case of glycogen storage diseases type 1 with renal stone as initial manifestation of disease at 2 months of age. There were case reports of recurrent renal calculi in older age group with this disease and considered to be arisen due to metabolic derangements. Although the exact mechanism of renal stones in glycogen storage disease is not clear, in this unique case occurrence of renal stones at 2 months of age suggests that the pathogenesis of renal calculi is probably multifactorial or a part of disease.

Sturge-Weber Syndrome Patient Registry: Delayed Diagnosis and Poor Seizure Control

To examine the symptomatology and treatment of Sturge-Weber syndrome (SWS) from a large patient registry to identify common symptoms, clinical outcomes, and areas of unmet clinical need. An online patient questionnaire was completed by 628 patients with clinically diagnosed SWS and/or a port-wine birthmark over a 19-year period. Statistical analysis focused on seizures as a primary outcome measure, as well as associated neurologic, ophthalmologic, and dermatologic attributes to understand some of the natural history of the disorder. The majority (92%) of patients had a port-wine birthmark, and 60% of the patients had neurologic symptoms, including seizures and stroke-like episodes. Glaucoma was present in 48% of the patients. Other common symptoms included behavioral (46%) and hearing (or vestibular) disorders (24%). Delayed diagnosis of SWS beyond 1year after presentation of initial symptoms occurred in 16% of the patients, with 68% having clear preexisting comorbidities, especially headaches. Birthmarks on the forehead and scalp were associated with seizures (P<.001), whereas bilaterality of birthmarks was not. Only 49% of patients being treated for epilepsy were free of seizures. Seizures and glaucoma were the primary drivers for a diagnosis of SWS in patients with delayed diagnosis, and hearing (or vestibular) and behavioral problems were also prevalent. The diagnosis of SWS was delayed when the predominant symptom was headache. Seizure control was quite poor in many patients with SWS. Our findings highlight an important need for detailed, longitudinal data to improve our understanding of SWS and develop better treatment strategies for patients with this disorder.

2077 A Rare Case of Migratory Urticaria Causing Dysphagia During an Acute Flare of Ulcerative Colitis

INTRODUCTION: Ulcerative colitis (UC) is characterized by chronic mucosal inflammation limited to the colon. The most common manifestation of UC is progressively worsening hematochezia that may be accompanied by extraintestinal manifestations including, peripheral arthritis, uveitis, primary sclerosing cholangitis, fatty liver, venous/arterial thromboembolism, and pulmonary disease. Erythema nodosum (EN) and pyoderma gangrenosum (PG) are the most common dermatologic manifestations. Uncommonly, UC may present with unpredictable urticaria and angioedema that may be life threatening. We present a rare care of acute UC flare with migratory urticaria as the initial presenting symptom. CASE DESCRIPTION/METHODS: A 25-year-old woman with UC presented with 1 week of abdominal pain, bloody stools, bilateral ankle and knee pain with non-blanching rash over her right shoulder, left armpit, and left groin. GI PCR and C. difficile assay were negative. Rheumatoid factor, double stranded DNA, anti-cyclic citrullinated peptide antibodies, anti-Smith antibody, anti-ribonuclear protein, and C1 esterase inhibitor were negative. The patient was started on cetirizine with resolution of the arthralgia. However, new rashes were noted under right axilla and left antecubital fossa over a two day period. Patient subsequently developed dysphagia and left sided mandibular swelling. Indirect laryngoscopy was unremarkable. She was immediately treated with IV methylprednisolone and transitioned to a slow oral steroid taper over 3 months with improvement of gastrointestinal and dermatologic symptoms. Skin biopsies revealed superficial and mid-dermal perivascular lymphocytic infiltrate consistent with urticaria. DISCUSSION: This patient presented with unpredictable migratory skin lesions involving multiple mucosal surfaces that brought concerns of possible airway involvement. The etiology was initially unclear as limited infectious and rheumatologic work up was negative, as well as negative allergen and medication exposure. Cutaneous vasculitis was considered, however biopsy showed urticaria. Patient’s symptoms significantly improved after the initiation of oral steroids. Migratory urticaria with associated angioedema can be a manifestation of an acute flare of UC that warrants evaluation by otolaryngologist and prompt initiation of steroids. Glucocorticoids may address symptoms of a pro-inflammatory state while allowing for more time to rule out other etiologies of extraintestinal manifestations of a patient’s presentations.

LUMPS AND BUMPS: A COMMON COMPLAINT WITH SINISTER IMPLICATIONS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is exceedingly uncommon for malignancy to present as cutaneous metastases. In fact, cutaneous metastases as an initial manifestation of internal neoplasias represent only 0.8% of total cases; and implies, in general, aggressive disease and poor prognosis. We present an atypical manifestation of non-small cell lung cancer (NSCLC) initially presenting as tender cutaneous nodules. CASE PRESENTATION: Patient is a 69 year-old female with pertinent medical history of 70 pack-year tobacco abuse who presented with a complaint of multiple painful, ulcerating skin nodules. 2 months prior to admission, she was seen by her physician for skin lesions and was prescribed a short course of antibiotics without resolution. At admission, patient reported a 1 month history of fatigue, unintentional 15 pound weight loss, and diffuse myalgias. Initial vital signs revealed normal temperature, heart rate of 113 bpm, respiratory rate of 16 breaths per minute, saturating 97% on room air. Labs revealed leukocytosis at 19.8 k/mm3 and lactic acid level of 3 mmol/L. She was suspected to have sepsis secondary to cellulitis. She was given 30 mg/kg fluid bolus and started on broad spectrum antibiotics. On examination, she had multiple ulcerated subcutaneous skin nodules on her chest, abdomen, inguinal area, and scalp. Radiographic imaging revealed a large left upper lobe mass with extensive pulmonary nodules concerning for malignancy. Imaging of her head revealed numerous supra and infratentorial metastatic lesions. Punch biopsy of a skin nodule was taken. Immunohistochemical (IHC) testing was positive for pankeratin and cytokeratin 7, but were negative for any neuroendocrine markers. Biopsy and IHC were consistent with poorly differentiated non-small cell lung adenocarcinoma. DISCUSSION: Cutaneous involvement among patients diagnosed with NSCLC is a rare finding, affecting 2.8%. Even less uncommon as the initial presenting symptom. Patterns of cutaneous metastases vary among women and men. Breast cancer, colorectal cancer, and melanoma frequently metastasize to the skin in women. In men; melanoma, lung cancer, and colorectal cancer are the most common sources of cutaneous metastases. Cutaneous metastases can present asymptomatically or be associated with pain and tenderness. Furthermore, they can often be mistaken for inflammatory dermatosis, infectious cellulitis, bullous or papulosquamous lesions. CONCLUSIONS: While rare, cutaneous manifestation can be the first sign of metastatic disease and often purports a poor prognosis. Therefore, it is important to recognize and evaluate abnormal skin lesions in the correct clinical context with appropriate clinical measures such as history, physical exams, imaging, and biopsy with histochemical staining. Reference #1: Alkhayat H, Hong CH. Cutaneous Metastases from Non-Small Cell Lung Cancer. J Cutan Med Surg. 2006 Nov-Dec;10(6):304-7. Reference #2: Ardavanis A, Orphanos G, Ioannidis G, Rigatos G. Skin Metastases from Primary Lung Cancer. Report of Three Cases and a Brief Review. In vivo. 2001; 20(5):671-3. Reference #3: Baldeo C, Ali R, Seeram V, House J. Lung Cancer Presenting as Soft-Tissue Metastasis. Case Rep Oncol. 2015;8:185-188. DISCLOSURES: No relevant relationships by Brandon Cherry, source=Web Response No relevant relationships by Menalee Hapuarachchi, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Harsh Patel, source=Web Response

1246 Patients With Eosinophilic Gastritis and/or Eosinophilic Gastroenteritis Endure a Lengthy Path to Diagnosis and Experience Persistent Symptoms After Diagnosis

INTRODUCTION: Eosinophilic gastritis (EG) and eosinophilic gastroenteritis (EGE) are chronic diseases characterized by elevated eosinophils in gastrointestinal (GI) tract biopsies. Patients with EG and/or EGE (EG/EGE) suffer from a decreased quality of life due to debilitating GI symptoms, a lengthy path to diagnosis, and lack of safe and effective treatment options. Here we utilize a large, highly representative claims database of ∼300 million US individuals to characterize the real-world diagnosis and management of adult patients with EG/EGE. METHODS: EG/EGE patients were identified by having ≥1 claim with a diagnosis code for EG and/or EGE (ICD-10-CM code K52.81) from Aug 2008 to Oct 2018 from Symphony Health's PatientSource® data. This analysis is focused on 3,458 unique adult patients (≥18 years) who had continuous claims data coverage for ≥3 years before and ≥1 year after EG/EGE diagnosis. RESULTS: Mean time from initial symptom presentation to EG/EGE diagnosis was 46.9 months; factors contributing to delayed diagnosis included delayed gastroenterologist referral, delayed endoscopy (Table 1), failure to diagnose on first endoscopy (39% of patients) and lack of routine biopsy/histopathology (65% of endoscopies). In the 12-month period following EG/EGE diagnosis, a majority of patients (56%) continued to experience GI symptoms, including abdominal pain, diarrhea and vomiting. Symptoms were documented by a healthcare provider at a mean frequency of 3.3 times per year. Overall, 32% of patients were treated with systemic corticosteroids (most commonly prednisone or prednisolone) and 6% received enteric-coated topical steroids (budesonide). Patients treated with systemic corticosteroids received a mean of 3.3 prescriptions per year, with the majority (59%) receiving more than one prescription per year. Persistence of GI symptoms was not related to treatment with systemic corticosteroids (Table 2). CONCLUSION: Patients with EG/EGE endure a lengthy path to diagnosis, and many continue to experience chronic, persistent GI symptoms after confirmed diagnosis despite frequent treatment with systemic corticosteroids. The lack of standard diagnostic processes and therapeutic options may prolong patient suffering due to uncontrolled symptoms. This study highlights the need for heightened disease awareness, standardized diagnostic criteria, and availability of safe and effective treatment options to improve the care of patients with EG/EGE.

Concussion Symptom Profiles Among Child, Adolescent, and Young Adult Athletes.

(1) To examine how age influences initial symptom presentation following concussion; and (2) to determine whether specific symptom profiles are associated with duration of postconcussion symptoms, and whether they vary by age group. A total of 689 patients (20% children 7-12 years of age, 69% adolescents 13-18 years of age, and 11% young adults 19-30 years of age) were seen and diagnosed with a concussion within 21 days after injury. Patients completed the Post-Concussion Symptom Scale (PCSS) and were followed until they no longer required care. Two specialty care sport concussion clinical practices. Overall PCSS score was obtained, as well as severity ratings from somatic, vestibular-ocular, cognitive, sleep, and emotional symptom domains. We also calculated total symptom duration time. No significant main effect of age, or age by sex associations were identified among the symptom domains. Females endorsed a higher somatic symptom severity rating than males (9.8 ± 6.7 vs 8.1 ± 6.7; P = 0.03). For patients between 7 and 12 years of age, higher somatic [β-coefficient = 1.57, 95% confidence interval (CI), 1.47-1.67] and cognitive (β-coefficient = 2.50, 95% CI, 2.32-2.68) symptom severities were associated with longer duration of concussion symptoms. Among adolescents, longer total symptom duration was associated with more severe somatic (β-coefficient = 1.25, 95% CI, 0.34-2.15) and vestibular-ocular (β-coefficient = 2.36, 95% CI, 1.49-3.23) symptoms. Within 21 days after concussion, symptom-reporting behavior seems to be similar across the age spectrum, but the relationship between symptom profiles and time to symptom resolution varies by age. Although overall symptom ratings are beneficial in determining clinical pathways, symptom domain use may provide a beneficial method to determine individualized patient care that differs between children and adolescents after concussion.

Highly Elevated Cerebrospinal Fluid Total Tau Level Reflects Higher Likelihood of Non-Amnestic Subtype of Alzheimer's Disease.

Cerebrospinal fluid (CSF) levels of total tau (t-tau) protein are thought to reflect the intensity of the neuronal damage in neurodegeneration, including Alzheimer's disease (AD). The recent link of CSF t-tau to rapidly progressive AD raises the question among other AD clinical variants regarding CSF t-tau. We investigated the clinical phenotypes of AD patients with varying CSF t-tau levels. We tested the hypothesis that highly elevated CSF t-tau level would have a higher likelihood of presenting with atypical non-amnestic variants of AD. Retrospective comparative case study of 97 patients evaluated in a memory clinic with clinical presentation and CSF biomarkers consistent with AD. We compared the age, sex, education, APOEɛ4 status, Montreal Cognitive Assessment (MoCA) score, clinical phenotype, and MRI volumetric measures by CSF t-tau quartile at baseline. Multivariable logistic regression models were used to evaluate if CSF t-tau levels predict non-amnestic presentations controlling for covariates. Non-amnestic AD had a higher median CSF t-tau level compared to amnestic-AD (p = 0.014). Each 50 pg/ml increase in CSF t-tau was associated with an increase in the odds of having a non-amnestic presentation (7.4%) and aphasia (10.6 %) as the initial presenting symptom even after taking into account; age, sex, education, APOEɛ4, MoCA, and CSF Aβ42. Logopenic AD had higher t-tau and p-tau levels compared to other variants. Highly elevated CSF t-tau levels could indicate more cortical involvement presenting with early non-amnestic symptoms in atypical AD subtypes, particularly in the logopenic variant.

A Contemporary Medicolegal Analysis of Injury Related to Peripheral Nerve Blocks

Background: Closed malpractice claims can provide insight into low-frequency adverse events in many areas of perioperative and chronic pain care. Over the last decade, there have been changes in surgical and regional anesthetic practice, likely impacting adverse event patterns. Given the wide variability and low frequency of complications associated with peripheral nerve blocks, the study of closed malpractice claims offers an opportunity to examine adverse events, and the patient, technical, and provider factors that led to the claim. Knowledge gained from examination of closed claims has already resulted in multiple improvements in processes of care and patient safety. Objectives: An investigation of the factors that contributed to medicolegal claims against anesthesia providers related to peripheral nerve blocks. Study Design: Retrospective analysis. Setting: Inpatient and outpatient surgery facilities. Methods: The Comparative Benchmarking System database is a medical liability database that contains more than 400,000 malpractice claims from more than 400 academic and communitybased institutions accounting for over 30% of malpractice claims in the United States. The present investigation reviewed all (n = 113) available closed malpractice claims related to regional anesthesia (RA) in surgical patients closed between 2006 and 2016, and investigated factors that may have contributed to patient injury, including type of nerve block, type of surgery, nerves injured, resulting neurologic deficits, and potential factors contributing to the injury. Results: Our data analyzed 62 claims related to RA and showed that most closed claims were classified as permanent minor injuries. The greatest number of claims were for brachial plexus injuries associated with interscalene blocks performed for shoulder or rotator cuff repairs. Femoral and sciatic nerve blocks with resulting lower extremity injuries were the most common nerve blocks resulting in payment. The largest contributing factor to these injuries was noted to be “Technical Knowledge/Performance” of the regionalist followed by “Pre-existing Injury/Radiculopathy.” Symptom onset from these claims was most likely to be delayed with the leading initial presenting symptom being paresthesia. Limitations: It is difficult to establish cause-effect relationship, and the small sample size limits the ability to detect clinical differences and associations with specific comorbidities or techniques. There was also limited information related to regional anesthetic techniques and medications used that would have helped explore further relationships between the procedure and cause for litigation. Conclusions: There remains significant room for risk reduction in regional anesthetic practice. Patterns based on the analysis of closed claims show that interscalene blocks are the most common peripheral nerve block resulting in litigation, even when compared with other blocks involving the brachial plexus. Furthermore, patients with existing nerve injury/radiculopathy may also warrant alternative techniques or greater emphasis during informed consent on the increased risk of injury. As most of the presenting symptoms associated with claims are delayed, an opportunity for improvement in postregional care may be better communication with patients following discharge to discuss their postoperative recovery. Key words: Regional, pain, anesthesia, complications, closed claims, liability, nerve, block, injury

Comparison of Attention-Deficit/Hyperactivity Disorder Practice in Adults According to a Training Background in Child Psychiatry.

Objectives:Awareness of attention-deficit/hyperactivity disorder (ADHD) in adults has significantly increased; however, clinical data specific to the Korean population are insufficient. Clinical experience of ADHD may differ based on whether psychiatrists have received pediatric psychiatry-specific training. In order to prepare a practice parameter for adult ADHD patients in Korea, we examined questionnaire data to observe how pediatric psychiatry training could affect clinical practice for adults with ADHD.Methods:A questionnaire about the diagnosis and treatment process was distributed to both general psychiatrists (GPsy) and child and adolescent psychiatrists (CAP) at the summer and winter workshop meetings of Korean Academy of Child and Adolescent Psychiatry.Results:In total, 142 psychiatrists participated in the survey (86 GPsy, 56 CAP). GPsy and CAP preferred pharmacotherapy (GPsy 82.40%, CAP 64.30%) as the primary treatment option and answered that the clinical psychiatric interview is the most necessary step in diagnostic assessment (GPsy 22.16%, CAP 19.00%). The GPsy responded with an optimal and average treatment duration that was shorter than that reported by CAP.Conclusion:Identification of the initial presenting symptom as the correct diagnosis and the optimal duration of pharmacotherapy differed between GPsy and CAP in practice, whereas concepts in diagnosis and treatment of ADHD in adults were similar for both groups. These results suggest the urgent need for the Continuing Medical Education program for psychiatrists treating adults with ADHD.

Orbital Metastasis From Urothelial Carcinoma: A Comprehensive Literature Review.

To review the clinical features of orbital and choroidal metastases from urothelial carcinomas of the urinary tract among cases reported in the literature, and to describe a case of orbital metastasis from bladder cancer presenting as apparent internuclear ophthalmoplegia. Case reports of orbital and choroidal metastases from urothelial carcinomas published in the literature from 1965 to 2018 were reviewed. Data collected included patient demographics, cancer stage and primary site, time to onset of ocular symptoms, length of presenting ocular symptoms, types of primary ocular symptoms, diagnostic imaging, histology, systemic and ocular treatments, and survival time. Twenty-eight cases of urothelial carcinoma with metastasis to the orbit or choroid were reviewed. Men were significantly more likely to suffer from this condition than women (p = 0.011). The average age of presentation with orbital symptoms was 63 years, with an average time of 19 months between primary cancer diagnosis and onset of orbital symptoms. Twenty-two patients had metastasis to the orbit and 6 to the choroid. In 4 cases, ocular deficits secondary to orbital and/or choroidal metastases were the initial presenting symptoms in patients with previously undiagnosed urothelial carcinoma. The most commonly noted primary ocular symptoms and signs consisted of decreased visual acuity, decreased ocular motility, proptosis, and diplopia. Average survival from onset of ocular symptoms was 4.67 months. Urothelial carcinoma may metastasize to the orbit or choroid; furthermore, its presentation may mimic internuclear ophthalmoplegia. It is recommended that any patient with visual symptoms and known urothelial cancer should undergo expedited workup for metastatic disease.

Presenting symptoms in inflammatory bowel disease: descriptive analysis of a community-based inception cohort

BackgroundFew data are currently available on the initial presenting symptoms of patients with inflammatory bowel disease (IBD).MethodsWe evaluated the initial symptom presentation of patients with IBD in the Ocean State Crohn’s and Colitis Area Registry (OSCCAR), a community-based inception cohort that enrolled Rhode Island IBD patients at time of diagnosis with longitudinal follow up. A 41-question symptom inventory was administered at time of enrollment to capture symptoms experienced during the 4 weeks preceding diagnosis of IBD. Frequencies of presenting symptoms were calculated. Principal component analysis (PCA) with promax rotation was used to examine possible symptom profiles among Crohn’s disease (CD) and ulcerative colitis (UC) patients, respectively. Using the Scree plot, the 4-component solution was found to be optimal for both CD and UC.ResultsA total of 233 CD and 150 UC patients were included. The most common presenting symptoms in CD were tiredness/fatigue (80.6%) and abdominal pain (80.4%) while passage of blood with bowel movements (BM) (86.6%) and loose/watery BMs (86.5%) were most common in UC. The 5 symptoms with greatest differences between UC and CD were passage of blood with BM (UC 86.6%/CD 45.3%), urgent BM (UC 82.5%/CD 63.9%), passage of mucus with BM (UC 67.7%/CD 36.9%), passage of blood from the anus (UC 59.7%/CD 32.1%), and anxiety about distance from bathroom (UC 59%/CD 38.7%). The PCA analysis yielded a 4 symptom components solution for CD and UC.ConclusionThe most common presenting symptoms in CD are fatigue and abdominal pain while in UC bloody BM and diarrhea are most common. Distinct symptom phenotypes are seen with PCA analysis. Our study demonstrates symptomatic similarities and differences between CD and UC and suggests that patients may also be classified by symptom phenotype at time of diagnosis.

49: Surgical assessment of chronic pelvic pain

This is an educational video designed to describe indications for surgical intervention in the setting of chronic pelvic pain, and to outline tips and tricks for a thorough and successful diagnostic laparoscopy to evaluate for endometriosis. Endometriosis is a chronic inflammatory condition marked by ectopic endometrial glands and stroma. The gold standard of diagnosis is based on histologic confirmation obtained from surgical evaluation. Women with chronic pelvic pain who have failed medical management, desire conception, or who have pelvic imaging abnormalities are candidates for a diagnostic laparoscopy to evaluate for endometriosis. Initial presentation of symptoms of endometriosis to formal diagnosis is often delayed for years, which also suggests a delay in treatment. A diagnostic laparoscopy consists of a thorough evaluation of the abdominal and pelvic organs with photo documentation. Peritoneal biopsies should be collected at areas suspicious for endometriosis or other abnormalities. If no pathology is visualized, it may be prudent to collect random peritoneal biopsies for evaluation. Chromopertubation may be performed depending on the patients’ fertility goals. Perioperative counseling is crucial to discuss and evaluate for other sources of pelvic pain, review potential surgical findings and to develop a long-term treatment plan for acute and chronic pain. Chronic pelvic pain is a complex condition that requires comprehensive evaluation, inclusive of medical and surgical management.

Clinical Features and Correlates of Excessive Daytime Sleepiness in Parkinson's Disease.

Objective: To explore the clinical features and correlates of excessive daytime sleepiness (EDS) in a Chinese population of Parkinson's disease (PD) patients.Methods: Patients with clinically established or clinically probable PD were recruited. Clinical and demographic data were collected, and participants were evaluated using standardized assessment protocols. Patients were divided into PD with EDS and PD without EDS groups based on the Epworth sleepiness scale (ESS) scores, with a cutoff score of 10. Clinical manifestations were compared between patients with and without EDS, and correlates of EDS were also studied. In addition, the relationship between EDS and poor nighttime sleep quality was analyzed.Results: A total of 1,221 PD patients were recruited in our study. The mean ESS (min, max) score was 7.6 ± 6.1 (0, 24), and 34.1% of the patients had ESS scores ≥10. No difference was seen in lifestyle (except for alcohol consumption), environmental factors, BMI, levodopa equivalent dose (LED), initial presentation of motor symptoms, motor subtype, and wearing off between patients with and without EDS. The PD with EDS group had a higher proportion of male patients and a higher average patient age. Moreover, the PD with EDS group showed older age at PD onset, lower educational level, and longer disease duration. Patients with EDS had higher scores on the Hoehn-Yahr scale and the Unified Parkinson's Disease Rating Scale (UPDRS) parts I, II, and III score, more severe non-motor symptoms, and poorer quality of sleep and life. Logistic regression analyses demonstrated that EDS was associated with male sex, age, cognitive impairment, PD-related sleep problems, rapid eye movement sleep behavior disorder (RBD), and worse quality of life (QoL).Conclusion: EDS is a general clinical manifestation in PD, and there were significant differences in clinical features between patients with and without EDS. Moreover, our study proved that many factors were associated with EDS, including male sex, age, cognitive impairment, PD-related sleep problems, RBD, and worse QoL. Understanding the clinical characteristics of EDS in PD patients may help identify EDS early, improve QoL, and reduce the occurrence of accidents.

Abstract TP581: Maternal and Fetal Outcomes in Women With Brain Arteriovenous Malformation Rupture During Pregnancy

Background: Intracranial hemorrhage (ICH) is often the initial presenting symptom for patients with brain arteriovenous malformations (bAVM), which is further complicated in the setting of pregnancy. There are no standard guidelines for management of pregnant women with bAVM, and few studies have reported on maternal and fetal outcomes in those with bAVM ICH. The purpose of this descriptive study was to review our case series for maternal and fetal outcomes in women with bAVM ICH during pregnancy. Methods: We conducted a retrospective review of our database for women between the ages of 15-50 years who presented with a bAVM ICH during pregnancy between 2000-2017. Demographics, angiographic characteristics, gestational age/trimester at ICH, mode and timing of AVM treatment, and maternal (e.g. modified Rankin Scale, mRS) and fetal outcomes (e.g. healthy or intrauterine fetal death) were recorded from the medical records. Results: We identified 16 bAVM cases who were pregnant at the time of ICH. Mean age of cases was 27±6.7 years, 56% were non-Caucasian, and 81% presented with an ICH during the second or third trimester. Of 16 patients, 2 terminated pregnancies in the 1 st trimester, 1 miscarried immediately after ICH, and 13 patients carried to term (69% delivered cesarean and 23% vaginal). Of 13 patients with live births, 77% received emergent AVM treatment (embolization+resection or resection only) at time of ICH, while 3 deferred treatment until after birth. The majority of bAVMs were Spetzler-Martin grade 2 or 3 (87%), 56% had deep venous drainage, and mean AVM size was 2.5±1.2cm. At 2-year follow-up, 85% of women had good outcomes (mRS 0-2). Only one patient did worse after AVM treatment due to a permanent neurological deficit. All cases had healthy fetal outcomes at time of delivery and at 2-yr follow-up. Conclusion: Our case series suggest good fetal and maternal outcomes in ruptured bAVM patients presenting during pregnancy, the majority of which were treated before delivery. Treatment of ruptured AVMs during pregnancy should be tailored to the needs of each specific patient in close consultation with the obstetrics and neurosurgery teams.

Paraneoplastic hyperbilirubinemia in metastatic prostate cancer and review of the current literature.

Paraneoplastic syndromes are functional clinical disorders caused by the direct effect of the primary tumor or metastasis. The initial presenting symptom of the patients may be associated with paraneoplastic manifestations. Paraneoplastic cholestasis is most frequently defined in association with renal cell carcinoma (Stauffer's syndrome), but it is an extremely rare clinical entity seen in association with prostate cancer. Etiology of cholestasis was investigated in the case diagnosed as metastatic prostate cancer who applied to the gastroenterology outpatient clinic due to complaints of ascites and jaundice that established the diagnosis of paraneoplastic hyperbilirubinemia. We observed improvement of his cholestasis with hormonotherapy used for prostate cancer.

Revisiting Rupture of Benign Thyroid Nodules after Radiofrequency Ablation: Various Types and Imaging Features

BackgroundTo evaluate the imaging features, clinical manifestations, and prognosis of patients with thyroid nodule rupture after radiofrequency ablation (RFA).MethodsThe records of 12 patients who experienced thyroid nodule rupture after RFA at four Korean thyroid centers between March 2010 and July 2017 were retrospectively reviewed. Clinical data evaluated included baseline patient characteristics, treatment methods, initial presenting symptoms, imaging features, treatment, and prognosis.ResultsThe most common symptoms of post-RFA nodule rupture were sudden neck bulging and pain. Based on imaging features, the localization of nodule rupture was classified into three types: anterior, posterolateral, and medial types. The anterior type is the most often, followed by posterolateral and medial type. Eight patients recovered completely after conservative treatment. Four patients who did not improve with conservative management required invasive procedures, including incision and drainage or aspiration.ConclusionThyroid nodule rupture after RFA can be classified into three types based on its localization: anterior, posterolateral, and medial types. Because majority of thyroid nodule ruptures after RFA can be managed conservatively, familiarity with these imaging features is essential in avoiding unnecessary imaging workup or invasive procedures.

Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

Clinical Outcomes in Patients with Gastric Adenocarcinoma Presenting with Upper Gastrointestinal Bleeding Initially

Introduction: Gastric adenocarcinoma presenting with upper gastrointestinal bleeding (UGIB) is uncommon and occurs in the late course of the disease. However, it is uncertain whether this bleeding predicts poor prognosis. Here, we aimed to evaluate the clinical outcomes of patients with gastric adenocarcinoma who initially presented with UGIB Methods: A total of 1,371 patients who were admitted with gastric adenocarcinoma were enrolled. Among them, a consecutive series of patients who were admitted with UGIB due to gastric adenocarcinoma as an initial presenting symptom were reviewed; of them, 44 patients were enrolled. Results: Twenty-four patients with cancer bleeding underwent curative gastrectomy, whereas 1,005 patients without cancer bleeding underwent curative gastrectomy (54.5% vs. 75.7%, P < 0.01). A male dominant pattern was typical in cancer bleeding patients (P < 0.01). Most patients (75.0%) had spontaneous resolution of bleeding, and the rate of successful therapeutic intervention was 91%. There was a significant difference in the rate of non-curative resection and palliative bypass surgery due to upgraded stage between the patients with gastric cancer bleeding and without bleeding (P < 0.01). Among the patients having curative resection, there was no statistical difference in disease-free survival the patients with gastric cancer bleeding and without bleeding (P = 0.31). Conclusion: In patients with UGIB caused by gastric adenocarcinoma as an initial presentation, the probability of curative resection was significantly low. When patients with gastric adenocarcinoma initially present with UGIB, the cancer stage can be underestimated; thus, a careful staging work-up should be needed.563_A Figure 1. Therapies for bleeding included hemoclipping (n = 9) (Figure 1A), electrocoagulation (n = 5) (Figure 1B), epinephrine injection (n = 1), angiographic embolization (n = 1) (Figure 1C)563_B Figure 2. There was no difference in DFS or progression-free survival in patients who underwent curative resection (n = 24) compared with age- and sexmatched controls (P = 0.31) (Figure 2)

A Case of Low Grade Astrocytoma Induced Progressive Episodic Intractable Nausea and Vomiting

Chronic nausea and emesis, which may serve a protective function, pose a diagnostic challenge with a broad differential and contribute to numerous health care visits each year. We present a case of chronic intermittent nausea/emesis due to a brain mass without classic neurologic findings. A 36 year-old male presented with 3 months of intermittent episodes consisting of: relentless nausea, up to 10 bouts of forceful emesis a day, and PO intolerance. Episodes would last 2-3 days and occur once every 6 to 8 weeks with asymptomatic intervals between episodes. He denied preceding events, food triggers, and other related symptoms. He was taking lisinopril and aspirin and denied over the counter supplements. He remained afebrile and hemodynamically stable. Physical exam noted active emesis and non-peritoneal left quadrant pain. CBC, CMP, TSH, lipase were within normal limits. Urine drug screen and EtOH level were negative. CT abdomen/pelvis and right upper quadrant ultrasound were unremarkable. EGD revealed a small hiatal hernia with LA grade B esophagitis, chronic active gastritis, no food retention, and no evidence of obstruction. A trial of high dose PPI was unsuccessful. Subsequent imaging of the brain revealed a 1.6cm right posterior high frontal cortical mass without mass effect that was suspected to be benign; therefore, plan was for conservative management. However, in the following months, the patient had progression of symptoms with episodes increasing to once every 4 weeks and lasting 1-2 weeks. An elective sub-total resection of the mass was performed. Pathology demonstrated a diffuse grade II astrocytoma. The patient reported complete symptom resolutions at his 3-month follow up exam. The most common symptoms associated with brain masses are headache and neurologic deficits. However, nausea/vomiting are the initial presenting symptoms in up to 13% of cases. Nausea/emesis are typically the result of increased intracranial pressure, mass effect, involvement of the posterior fossa leading to gastroparesis, or involvement of the area postrema at the chemoreceptor trigger zone. However, lesions involving the higher cortical centers (such as the frontal lobe) can also lead to nausea and emesis. We highlight a rare case of a frontal astrocytoma initially presenting with unexplained nausea/emesis with resolution of symptoms following resection. It is important to consider the extra-intestinal etiologies for common gastrointestinal symptoms.3085_A Figure 1. MRI Brain Horizontal3085_B Figure 2. MRI Brain Sagittal