Previous Smoking History Research Articles

Study of factors affecting mortality and morbidity in patients presenting with peritonitis due to duodenal ulcer perforation

Background: Peptic ulcer disease in the general population had lifetime prevalence of 5-10% with incidence of 0.1–0.3% per year. Despite the tremendous improvement in preventive therapies, the rate of complication of this disease is still high and is burdened by high morbidity and mortality. In present study, we aimed to study factors affecting mortality and morbidity in patients presenting with peritonitis due to duodenal ulcer perforation at our tertiary hospital. Material and Methods: Present study was single-center, prospective, observational study conducted in patients admitted, diagnosed with duodenal ulcer perforation and surgically treated at our hospital. Results: In present study period total 56 patients were studied. All were male, most common age group was 51-60 years (37.5%) followed by 41-50 years (23.21%). Duration from onset of symptoms to admission was >24 hours (30.36%) in most of patients followed by 12-24 hours (28.57%). Most commons symptoms were pain in abdomen (100%), vomiting (100%). Anaemia (37.5%), LRTI and Pulmonary complications (19.64%), Diabetes mellitus (12.5%) and Hypertension (10.71%) were common comorbidities noted. Associated risk factors were previous history of PUD (41.07%), Alcohol use (64.29%), Cigarette smoking (51.79%) and Use of NSAIDs (12.5%). Presence of free gas under diaphragm was noted in 83.93% patients. Intraoperatively duodenal perforation diameter was 1–5 mm (60.71%) in most of patients followed by 6–10 mm (23.21%). Only 1 patient had duodenal perforation diameter was > 20mm. Common postoperative complications were wound infection (37.5%) and pulmonary infection (21.43%). In present study mortality within 1 month was noted in 13 patients (23.21%). Most common factors related to mortality were delayed presentation > 24 hours (61.54%), age > 60 years (46.15%), diabetes mellites (38.46%), Size of perforation > 1 cm (38.46%) and septicaemic shock (23.08%). Conclusion: Delayed presentation > 24 hours, age > 60 years size of perforation > 1 cm were common factors related to mortality in duodenal ulcer perforation patients.

Bronchodilator Response in Airflow Obstruction after Treatment of Pulmonary Tuberculosis- A Retrospective Analysis

Introduction: Pulmonary Tuberculosis (PTB) is a risk factor for the development of Obstructive Ventilatory Disorder (OVD). Evaluation of the response to the bronchodilator in patients with OVD, as the exclusive consequence of the PTB sequel, has not been studied. Aim: To evaluate response of Bronchodilators (BD) in patients treated for PTB with airflow obstruction and without any previous pulmonary diseases or smoking history. Materials and Methods: A retrospective analysis of data (n=60) was done from February 2014 to February 2015, from a previous multicentric study that used 378 participants. There were data of 60 patients without any previous pulmonary diseases, smoking history, and with OVD or OVD with reduced Forced Vital Capacity (FVC). The participants performed spirometry under BD. The BD response was considered positive when an increase in Forced Expiratory Volume in the first second (FEV1) and/or FVC ≥12% was observed (as a percentage of change from baseline) and ≥200 mL (in absolute values) after administering salbutamol. To verify association between variables and response to BD, the Fisher-Exact Test was performed (p≤0.05 were considered statistically significant). The variables were analysed using SPSS version 22.0. Results: Of the 59/60 patients that underwent spirometry before and after the use of BD, 13/59 (22.03%) presented a positive response. Among those, 7/59 (11.87%) had FEV1 response, 5/59 (8.47%) FVC response and 1/59 (1.69%) presented a simultaneous response in FEV1 and FVC. Association between socio-demographic, clinical and radiological variables and BD response were not significant. Conclusion: The response to BD was observed in a quarter of patients with OVD, due to a likely structural change caused by Tuberculosis (TB).

Does the COPD assessment test associate to skeletal muscle dysfunction in individuals with chronic obstructive pulmonary disease?

Background: Skeletal muscles provide the mechanical basis for breathing and movement, and skeletal muscle dysfunction which is frequently observed in individuals with chronic obstructive pulmonary disease (COPD) has important clinical implications. Aims: The objective of the present study was to investigate whether the COPD assessment test (CAT) score may be associated with quadriceps muscle thickness, handgrip strength, peripheral muscle endurance and respiratory muscle strength in individuals with COPD enrolled in a pulmonary rehabilitation program. Methods: This is a cross-sectional study with evaluation of the following outcomes: quadriceps muscle thickness (ultrasonography), handgrip strength (muscle strength dynamometer), peripheral muscle endurance (30-second sit-to-stand test) and respiratory muscle strength (manovacuometry). Results: Twenty-three individuals (65 ± 10.1 years; GOLD I (n=2), II (n=8), III (n=7) and IV (n=6)) participated in the study. The CAT score correlated negatively and moderately with handgrip strength (r=-0.655; p<0.001), negatively and moderately with quadriceps muscle thickness (r=-0.562; p=0.005) and peripheral muscle endurance (r=-0.573; p=0.004). There was no correlation between CAT score and respiratory muscle strength. The multiple linear regression model including the variables quadriceps muscle thickness, handgrip strength and peripheral muscle endurance was the best to predict the CAT score, explaining 65% of the variance. Conclusions: Our results suggest that the CAT score was associated with skeletal muscle dysfunction through quadriceps muscle thickness, handgrip strength and peripheral muscle endurance in a sample composed predominantly of women with COPD, ex-smokers or without previous smoking history enrolled in a pulmonary rehabilitation program.

Neutrophil - Lymphocyte Ratio as a Reliable Predictor of Postoperative Outcome And Mortality In Delayed Cases Of Peripheral Arterial Embolism

Introduction: Peripheral arterial embolism (PAE) continues to pose a challenge to vascular surgeons and remains to be characterized by high morbidity, limb threat and mortality, often requiring urgent revascularization. Contemporary untreated arterial embolism is among the leading causes of morbidity and mortality within the vascular field. Detection of a fast and reliable biomarker for risk stratification and early post-treatment prognosis is important for those with PAE, so that individuals at high risk can be accurately treated and targeted for prevention. Complete blood count is inexpensive, comparatively routine, and is a practical laboratory test that gives important information about the patient’s formed blood contents. Routine peripheral blood counts may be useful in diagnosis and prognosis of many disorders, including peripheral vascular ischemic incidents. Neutrophil - lymphocyte ratio (NLR) has been shown to be an independent predictor of early and midterm amputation in patients with acute limb ischemia after revascularisation. Methods: Data was collected retrospectively from hospitalised patients, in the Vascular Surgery Clinic of University Hospital, Stara Zagora, Bulgaria, who had a diagnosis of PAE, from January 2010 to January 2019. Inclusion criteria were clinical data of an ischemic embolic incident of the limbs, untreated at least 12 hours from the onset of symptoms. Results: A single cutoff point was chosen to better inform clinical practice at a value of NLR 4.55, to maximize sensitivity and specificity. The majority of patients from the group Who had a NLR under 4.55 had mild symptoms. Older patients however, were significantly more likely to have an elevated NLR. The incidence of diabetes and hypertension were not significantly higher in any group. There was a higher incidence of primary major amputations in the elevated NLR group. Of the 25 deaths during the course of the study, which were specifically attributed to cardiac causes, twelve (13.8%) occurred within the elevated NLR group and thirteen (8.7%) in the low NLR group. Conclusion: NLR is an easily accessible biomarker that conveys important information about the patient’s inflammatory activity and can be easily calculated from the differential WBC count, which is routinely performed on admission and is universally available. An elevated NLR could potentially be included in addition to the most common risk factors for mortality and poor post-treatment outcome including cardiac causes, age >70 years, history of stroke or previous MI, renal failure, and smoking history (at any time).

Abstract 16324: The Overall Haemostatic Potential: A Novel Coagulation Measure Associated With Sex-specific Differences in Early Atherosclerosis and Metabolic Dysfunction

Introduction &amp; Aim: Plaque micro-ruptures and associated thrombosis are a contributor to the progression of coronary artery disease (CAD). We sought to determine if disorders of haemostasis detectable by a global coagulation assay was a novel risk factor for CAD, or if hypercoagulation was associated with any of the traditional cardiac risk factors. Methods: Using the BioHEART biobank of clinical data, imaging data and pathology specimens, a cohort of patients (mean age 62.9 +/- 9.9 years, n=103 female, 103 male) had platelet poor plasma assessed by the overall haemostatic potential (OHP) assay. This assay measures the integrated effect of procoagulant, anticoagulant and fibrinolytic factors via calculation of area under a fibrin time curve. All patients had CT coronary angiograms scored; calcified plaque was identified by the coronary artery calcium score, and non-calcified plaque burden by a soft plaque score (SPS). Analysis was segregated by sex because of baseline differences in coagulation between males and females. Results: The OHP was found to be elevated in male patients who had non-calcified CAD [SPS&gt;0 - 10.4 +/- 0.6 (n=62) vs SPS=0 - 8.78 +/- 0.5 (n=41), p=0.04], male patients with obesity [BMI &gt;= 30 - 12.6 +/- 1.1 (n=26) vs BMI &lt; 30 - 8.8 +/- 0.4 (n=77), p&lt;0.01] and in female patients with hyperlipidaemia [hyperlipidaemic 11.8 +/- 0.6 (n=63) vs normolipidaemic 9.2 +/- 0.6 (n=40), p&lt;0.01]. No differences were seen in OHP with calcified CAD, hypertension, diabetes mellitus, current or previous smoking history, or significant family history of CAD. Conclusions: These results indicate that hypercoagulation is associated with more biologically active non-calcified plaque, and that disordered coagulation is associated with two significant cardiac risk factors in a sex-discrepant manner. These findings underscore the importance of global coagulation assessments as potential novel, sex-specific biomarker for subclinical atherosclerosis.

The Association between Prostate-Specific Antigen Velocity (PSAV), Value and Acceleration, and of the Free PSA/Total PSA Index or Ratio, with Prostate Conditions.

Introduction: Prostate-specific antigen velocity (PSAV) is used to monitor men with clinical suspicion of prostate cancer (PCa), with a normal cut-off point of 0.3–0.5 ng/mL/year. The aim of the study is to establish the predictive capacity of PSAV (value and acceleration) and of the free PSA/total PSA index or ratio. Method: Prospective multicentre observational study in 2035 men of over 47 years of age. Inclusion criteria: men who wished to be informed on the health of their prostate. Exclusion criteria: men with a previously diagnosed prostate condition. Groups: GA: (n = 518): men with serum PSA equal to or greater than 2.01 ng/mL. GB: (n = 775): men with serum PSA greater than or equal to 0.78 ng/mL and less than 2.01 ng/mL. GC: (n = 742): men with serum PSA less than 0.78 ng/mL. Variables: prostate-specific antigen (PSA); age; body mass index (BMI); PSA velocity (PSAV) (ng/mL per year); free PSA/total PSA index (iPSA); PSAV acceleration (increasing: positive, or decreasing: negative); prostate diagnosis (benign prostatic hyperplasia (BPH), prostatic intraepithelial neoplasia (PIN), or infectious and non-infectious prostatitis and prostatic adenocarcinoma (PCa)); de novo diagnoses of urinary tract diseases or conditions; concomitant treatments, diseases and conditions; final diagnosis of prostate health. Results: Mean age 62.35 years (SD 8.12), median 61 (47–94); age was lowest in GC. Mean BMI was 27.89 kg/m2 (SD 3.96), median 27.58 (18.56–57.13); no differences between groups. Mean PSAV was 0.69, SD 2.16, median 0.13 (0.001–34.46); PSAV was lowest in GC. Mean iPSA was 27.39 u/L (SD 14.25), median 24.29 (3.7–115); iPSA was lowest in GA. PSAV had more positive acceleration in GA and more negative acceleration in GC. There were 1600 (78.62%) cases of normal prostate or BPH, 322 (15.82%) cases of PIN or non-infectious prostatitis, and 113 (5.55%) cases of PCa. There were more cases of BPH in GC and more cases of PIN or prostatitis and cancer in GA (p = 0.00001). De novo diagnoses: 15 cases of urinary incontinence (UI), 16 discomfort/pain in LUT, 112 cases of voiding disorders, 12 urethral strictures, 19 hematuria, 51 cystitis, 3 pyelonephritis, 4 pelvic inflammatory disease; no differences were found between groups. In the multivariate analysis, PSAV and the direction of PSAV acceleration (positive or negative) were the variables which were correlated most strongly with prostate health. iPSA was associated with the presence of prostatitis, PCa, and BPH. Men in GA had more prostatitis, PCa, treatment with alpha blockers, and history of previous smoking. GB had more cases of BPH and more positive acceleration of PSAV. GC had more normal prostates, more BPH, more use of ranitidine, and more PSAV with negative acceleration. Conclusions: PSAV, direction of PSAV acceleration, and iPSA in PSA cut-off points of 0.78 ng/mL and 2.01 ng/mL in a priori healthy men over 47 predict the probability of benign or malignant pathology of the prostate.

Efficacy and Safety of Ticagrelor and Clopidogrel in Patients with Stable Coronary Artery Disease Undergoing Percutaneous Coronary Intervention.

Aim: The efficacy and safety of ticagrelor and clopidogrel in patients with stable coronary artery disease (SCAD) undergoing percutaneous coronary intervention (PCI) remain uncertain. Thus, this study aimed to compare the efficacy and safety of ticagrelor and clopidogrel in patients with SCAD treated with PCI. Methods: A total of 9,379 patients with SCAD undergoing PCI who received dual antiplatelet therapy (DAPT) were consecutively enrolled in two groups, namely, ticagrelor ( n =1,081) and clopidogrel ( n =8,298) groups. Major adverse cardiovascular and cerebrovascular events (MACCEs) and bleeding events according to ticagrelor or clopidogrel use were compared. Results: After propensity matching ( n =1,081 in each group), ticagrelor was associated with fewer MACCEs compared with clopidogrel (3.6% vs. 5.7%, hazard ratio [HR]=0.62, 95% confidence interval [CI] 0.41–0.93, p =0.019), and the difference between ticagrelor and clopidogrel for bleeding events was nonsignificant (4.0% vs. 3.2%, HR=1.24, 95% CI 0.79-1.93, p =0.356). On the other hand, the difference between ticagrelor and clopidogrel for net adverse clinical events was significant (4.1% vs. 6.0%, HR=0.67, 95% CI 0.46–0.98, p =0.039). In a multivariate analysis, the use of ticagrelor, number of stents, previous history of diabetes, previous history of smoking, and ACC/AHA type B2 or C lesions were considered independent predictors of MACCEs, while radial artery access, previous history of stroke, and weight ＜60kg were independent predictors of bleeding events. Conclusions Ticagrelor was associated with a lower incidence of MACCEs without an increased risk of bleeding events in patients with SCAD receiving PCI.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

E-cigarette, or Vaping, Associated Lung and Hepatic Injury.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy.

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. However, the association between clinical risk factors and left ventricular (LV) function in such patients is currently unclear. We studied 86 breast cancer patients with preserved LV ejection fraction (LVEF) and treated with anthracyclines, trastuzumab, or both. Echocardiography was performed before and 16days after chemotherapy. In accordance with the current position paper, clinical risk factors for CTRCD were defined as: cumulative dose of doxorubicin > 240mg/m2, age > 65-year-old, body mass index > 30kg/m2, previous radiation therapy, B-type natriuretic peptide > 100pg/mL, previous history of cardiovascular disease, atrial fibrillation, hypertension, diabetes, and smoking. The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (- 9.3 ± 10.8% vs. - 2.2 ± 10.2%; p = 0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%; p = 0.12). Moreover, the relative decrease in LVEF became greater as the number of risk factors increased. This study found multiple risk factors were associated with LV dysfunction following chemotherapy. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Smoking Is Associated With Longer Intensive Care Unit Stays in Spine Trauma Patients.

To determine the impact of smoking on intensive care unit (ICU) outcomes in patients who underwent operative fixation for spine trauma. Retrospective cohort study. Single academic level I trauma center. One hundred eighty-one consecutive surgical spine trauma patients from January 2010 to December 2014 requiring ICU stay. Patients with smoking history compared to patients with no previous smoking history. ICU length of stay, postoperative complications. There were 297 spine trauma patients identified, of which 181 had an ICU stay (61%). There were 96 patients in the smoker cohort (53%) and 85 in the nonsmoker cohort (47%). On univariate analysis, the smoking cohort had a significantly longer ICU length of stay (11.0 ± 12.0 days vs. 8.01 ± 7.98 days, P = 0.046). Adjusting for confounders, smoking (beta: 3.99, P = 0.023), age ≥65 years (beta: 7.61, P = 0.001), body mass index ≥30 (beta: 4.47, P = 0.010), and American Spinal Injury Association Impairment Scale (beta: -1.39, P = 0.013) were independently associated with increased ICU length of stay. Smoking was not significantly associated with pneumonia (P = 0.238) or adult respiratory distress syndrome (P = 0.387) on multivariate analysis. A history of smoking, older age, obesity, and increasing American Spinal Injury Association Impairment Scale was independently associated with increased ICU length of stay in patients with surgical spine trauma. This study highlights the health care burden of smoking in the trauma population and may help physicians triage scarce ICU resources. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smoking history and its relationship with comorbidities in patients with obstructive sleep apnea.

INTRODUCTIONCurrent knowledge on the correlation between smoking and comorbidities associated with obstructive sleep apnea (OSA) is limited. This study evaluated the smoking history of OSA patients and analyzed the association between smoking and OSA comorbidities.METHODSRetrospective analysis was performed in newly diagnosed OSA patients in our hospital, a tertiary medical center, from January 2016 to December 2019. In all, 1021 patients were enrolled and divided into two groups, non-smokers (n=796) and current/former smokers (n=225), in order to compare their clinical manifestations and polysomnographic results and to analyze the association between smoking and comorbidities.RESULTSCompared with the non-smokers, the current/former smokers had higher Epworth sleepiness scale (ESS) scores (9.3 ± 4.0 vs 8.5 ± 5.1; p<0.05), longer sleep latency (SL) [20.5 (12.3–39.3) vs 18.5 (10.0–34.0) minutes; p<0.05], and a lower nocturnal mean oxygen saturation (91.8 ± 3.6% vs 92.8 ± 3.4%; p<0.001). There was no significant difference in the apnea-hypopnea index (AHI) between the two groups. OSA patients with a history of smoking had significantly increased risk of hypertension (OR=2.09; 95% CI: 1.46– 3.01), chronic obstructive pulmonary disease (COPD) (OR=9.80; 95% CI: 4.73–20.33), gastroesophageal reflux disease (GERD) (OR=1.97; 95% CI: 1.19–3.27), and chronic pharyngitis (OR=1.83; 95% CI: 1.32–2.54).CONCLUSIONSNo significant association was found between previous smoking history and current OSA severity. OSA patients with a history of smoking had an increased risk of hypertension, COPD, GERD, and chronic pharyngitis.

Hidradenitis Suppurativa and Scrotal Elephantiasis Case Report

ABSTRACT Scrotal elephantiasis occasionally presents in conjunction with hidradenitis suppurativa (HS). A 39-year-old morbidly obese African American man, with a previous smoking history, has a 20-year history of HS complicated by a 3-year history of scrotal elephantiasis. His Hurley Stage III HS affects the scrotum, penis, lower abdomen, bilateral groin, and buttock regions. Although his scrotal edema is likely attributed to his history of HS, other causes were ruled out. A computed tomography scan of pelvis with intravenous contrast revealed edematous enlargement of the scrotum and multiple inflammatory abscesses consistent with HS. His condition was complicated by development of infection of the scrotal, perineal, and penile areas. He is currently on adalimumab 40 mg weekly and uses silvadene 1% cream topically. Improvement of his HS has been attributed to the current medical regimen and weight loss. He is responding well to implemented adalimumab for HS with no adverse effects reported. He has undergone several irrigation and debridement procedures for scrotal elephantiasis with success. He is currently preparing for gastric bypass surgery and lumpectomy after this procedure.

Real-world data of a cohort of patients with EGFR mutated metastatic non-small cell lung cancer (NSCLC), follow up of 52 months in Fundación Santa Fe de Bogota.

e19287 Background: In Colombia, clinical information about EGFR mutated metastatic NSCLC is deficient. The goal of this study is to describe the characteristics and outcomes of a cohort of patients as a real-world evidence from a single institution from Colombia. Methods: This is an observational study of a cohort of patients with EGFR mutated metastatic NSCLC. We did follow up for 52 months and analyzed molecular, clinical and epidemiological characteristics, progression free survival (PFS), overall survival (OSm) and treatment related complications. Results: Sixteen patients were included. 81.2% were female and 18.2% male patients. All patients with ECOG 0-2. Previous smoking history was reported in 31.2%. 25% of the patients had brain metastasis and 18.7% had high volume disease (three or more sites of metastasis). The mutations reported were: 62.5% exon 19 deletion, 31.2% L858R mutation, 0.06% exon 19 insertion, 12.5% truncal T790M mutation. The PFS and the OSm for the whole cohort were 14.6 months and 25 months respectively. As a first line of treatment 25% of the patients received erlotinib (PFS 11.7m and OSm 26.6m), 37.5% gefitinib (PFS 12m and OSm 14.6m), 25% afatinib (PFS 16.6m and OSm has not been reached) and 12.5% osimertinib without progression, during 10.5m of follow up. After 52 months, 50% of the patients had progressed. After the progression, rebiopsy was performed in all patients, T790M mutation was detected in 50%, and 50% of these patients died with OSm of 3m with a fast clinical worsening. In relation with grade 3-4 toxicity it was one case of hepatotoxicity with afatinib, with gefitinib 2/6 patients had diarrhea, with erlotinib one case of hematotoxicity and with osimertinib 1/6 patients developed hepatotoxicity. Conclusions: The clinical characteristics of our cohort was similar to previous reports in the literature. Additionally, molecular behavior was concordant with other reports in Latin America, with a higher incidence of exon 19 deletion. Gefitinib was the most frequent treatment used, probably due to non-availability of other therapies such as afatinib or osimertinib in our country until 2018 and 2019 respectively. There were no differences in PFS or OSm according to anti-EGFR treatment and molecular behavior. The OS was lower than reported in clinical trials in gefitinib treatment group, this finding requires validation in bigger cohort of patients, but is real world data that can partially explain these results.

SUN-908 Mediastinal Paraganglioma: A Rare Presentation of a Rare Tumor

BACKGROUNDParagangliomas (PPGL’s) are extra-adrenal chromaffin-cell originating tumors that arise from the para-aortic ganglia and are exceptionally rare making up only 1% of the mediastinal tumors. They are slowly growing and highly vascular tumors associated with high morbidity and mortality due to proximity and invasion into the heart, great vessels. The majority of them are asymptomatic and hence discovered incidentally. Surgical resection remains the standard of care with good long term survival. We describe a case of a young male with middle mediastinal PPGL who remained asymptomatic despite large functional tumor.CLINICAL CASEA 38-year old Arab male with no previous smoking history was referred to our hospital for evaluation of mediastinal mass that was incidentally noted on an echocardiogram done 1 year ago in his home country when he presented with intermittent exertional shortness of breath for 10 years. The workup done there with CT chest revealed a large mediastinal mass measuring 10.4×8.8×8.6 cm extending into ascending aorta, right pulmonary artery, right superior pulmonary vein, right and left atria as well as the main bronchi bilaterally invading the superior vena cava. However, he had no further treatment until he was seen 1 year later in the US at another institution where biochemical testing showed elevated plasma norepinephrine of 2697 (70-750 pg/ml, supine), dopamine 7667 (<30 pg/ml). 24hr-urine studies showed elevated normetanephrine of 3418 (111-419 mcg/24hr), metanephrine 3488 (200-614 mcg/24hr), and Homovanillic acid (HVA) 51.5 (<0.8 mg/24hr). He underwent endobronchial ultrasound with mediastinal tissue biopsy of the mass that revealed pheochromocytoma. The patient was subsequently referred for cardiovascular intervention at our hospital and endocrinology was consulted for pre-operative preparation. One week before surgery, he was started on doxazosin 2mg daily followed 3 days later by propranolol 10 mg twice daily and recommend high salt and fluid intake. The patient underwent surgical resection of the mass and pathology showed mediastinal PPGL. The postoperative course was complicated by bradycardia with the placement of a permanent pacemaker. He recovered well after surgery with the resolution of symptoms and a significant decline in catecholamines to urine normetanephrine of 385 mcg/24hr and metanephrine 497 mcg/24hrs. There was no evidence of metastatic or residual disease on follow-up CT chest 5 months later.CONCLUSIONThere are limited case reports of PPGL in the middle mediastinum. This case highlights that mediastinal PPGL’s can remain clinically silent for many years prior to the presentation which can lead to delayed diagnosis, yet a strong collaborative team approach between oncology, cardiovascular surgery and endocrinology can confer favorable clinical outcome.

SUN-913 A MEN-2a Syndrome Index Case Presenting with Adrenergic Crisis and Cardiogenic Shock Due to Bilateral Pheochromocytoma

Background: MEN-2A syndrome is commonly asymptomatic at diagnosis. Withal, pheochromocytoma presenting as cardiogenic shock is a recognized but exceptional occurrence. Case: A healthy 26-year-old female presented to the emergency department with precordial discomfort, headache and shortness of breath, starting that morning. She had a gum corrective surgery in the day before, was medicated with ibuprofen, pantoprazole and amoxicillin/clavulanic acid, and had previous history of migraine and smoking. Her blood pressure was high, and she had pulmonary edema and respiratory failure. ECG: sinus tachycardia, left axis deviation, and negative T wave in aVL. Analytically: leukocytosis, elevated myocardial necrosis markers (troponin I 1.29 ng/mL, normal < 0 ng/mL), and hyperlactacidemia. Transthoracic echocardiogram: severe left ventricular dysfunction, akinesia of the basal mid segments of all walls; image of thickening immediately above the aortic valvular plane. CT angiography: bilateral adrenal masses (9.2x9.2x10.8 cm on the right; 2.3x2.8x3.3 cm on the left), suggestive of pheochromocytoma. Cardiogenic shock led to patient transfer to our hospital for ECMO, in which she was maintained for 14 days. Pheochromocytoma was confirmed (normetanephrine 15689 µg/24h [normal < 390 µg/24h], metanephrine 15000 [normal < 320 µg/24h]) and adrenergic blockade initiated. Hospitalization complications and surgical risk delayed bilateral adrenalectomy to 1 month after admission. She initiated glucocorticoid and mineralocorticoid replacement, was transferred to the ward stable, and started a rehabilitation program before hospital discharge. Phosphocalcic metabolism was normal (PTH 38.7 pg/mL, normal 10–65 pg/mL). High calcitonin levels (87 pg/mL, normal <5 pg/mL) lead to the diagnosis of medullary thyroid carcinoma, followed by total thyroidectomy. MIBG showed “No foci of radiopharmaceutical overaptation related to norepinephrine transporter overexpression lesions.”, and genetic study revealed heterozygous variant c.1900T>C [p. (Cys634Arg)] in exon 11 of the RET gene, confirming suspicion of MEN-2A syndrome. As there was no family history of endocrine neoplasias, she was referred to genetic counselling for evaluation of family members. She maintains follow-up, currently treated with hydrocortisone 7.5 + 5 + 2.5 mg od, fludrocortisone 0.1 mg od, and levothyroxine 137 mcg, with improvement of functional capacity and general state (weight gain of 13 kg), recovery of left ventricular function, normal urinary metanephrines, and calcitonin < 2.0 pg/mL. Conclusions: To our knowledge, MEN-2A syndrome presenting with cardiogenic shock due to pheochromocytoma was not yet described. Knowledge of unusual presentations of rare syndromes is important to arise suspicion and improve differential diagnosis in life-threatening conditions as cardiogenic shock.

Warthin's tumour seems to be the most common benign neoplasm of the parotid gland in Germany.

Recent reports indicate an increase in the prevalence of Warthin's tumours (adenolymphoma) with percentages which exceed that of pleomorphic adenomas (PA) in the same registries. The purpose of this study is to analyse a large cohort of benign parotid tumours in relation to various demographic and other patients' characteristics that might affect their incidence. A retrospective review of prospective collected data was performed on all patients who have been operated for a parotid mass in the last 5years. A total of 474 patients with benign lesion were included in the study. Age, gender, smoking status, histological diagnosis, site of lesion, and size of tumour were recorded. Warthin's tumours were the most common benign lesions, found in 201 (42.4%) parotic glands followed by pleomorphic adenomas found in 138 (29.1%) of these surgical cases. Patients with WT had a mean age of 61.6years instead of 52years for PA patients (t = 6.589, p < 0.001). The vast majority (93%) of patients with WT had a current or previous history of smoking compared with 47% of PA patients (p = 0.001). There was a male predominance regarding WT with a male:female (M:F) ratio of 2.3:1, whereas the corresponding ratio of PA was 1:1.4. This study confirms the increased regional prevalence of WT reported in studies mainly carried out in central Europe. This could affect future management of WT, which remains largely controversial due to the extremely low malignant potential reported, concurrently with its higher rates of multiplicity and recurrence, as well as the moderately accurate results of FNA biopsies.

Correlation between QRS duration and cardiac output measured by left ventricular outflow tract velocity in patient with cardiac resynchronization therapy

Abstract Background Cardiac resynchronization therapy (CRT) is proved as an effective treatment for moderate to severe heart failure. It reduces all-cause mortality in patients with advanced heart failure. There is strong evidence that CRT reduces mortality and hospitalization, improves cardiac function and structure in symptomatic chronic heart failure patients with optimal medical treatment, severely depressed LVEF (i.e. &amp;lt;35%) and complete LBBB. However 30% of patients may show negative response to CRT therapy. Therefore, optimization of CRT therapy in patients with heart failure seems to be a main subject for study in our researches. Methods of optimization includes optimization of medical therapy, control of risk factors and comorbidities, and optimization of device implantation and programming. Overall, studying the correlation between QRS duration and cardiac output will improve CRT programming optimization techniques. Aim To study the correlation between QRS duration and cardiac output measured by left ventricular outflow tract (LVOT) VTI in patients with CRT implantation. Methods Study included 100 CRT already implanted patients, they are requested to do a simple electrocardiographic and echocardiographic study. The relation between post implant QRS and cardiac output are studied among the patients. Results There was negative significant correlation between QRS duration and LVOT VTI and SVi. The optimal cut off values for optimal response to CRT using ROC curves were 130msec for post implant QRS duration and 17.1 cm for LVOT VTI. Conclusion CRT response is more in female patients with lower BSA, and without previous history of IHD or smoking. There is a significant negative correlation between QRS duration and LVOT VTI. Post implantation cut off value of QRS duration (&amp;lt;130) predict higher LVOT VTI and also the post implantation benefit for the patient with CRT implanted.

QRS Duration as a Predictor of Left Ventricular Outflow Tract Velocity Time Integral in Patient with Cardiac Resynchronization Therapy.

Background:Cardiac resynchronization therapy (CRT) has a morbidity and mortality benefits in moderate to severe heart failure. It reduces mortality and hospitalization and improves cardiac function. It can be used according to the European guidelines in severely depressed left ventricular ejection fraction (i.e., ≤35%) and complete left bundle branch block. However, 30% of patients may show no benefit from CRT therapy. Therefore, prediction of CRT response seems to be an important subject for study in the current researches. We aimed to study the correlation between Surface ECG QRS complex duration (QRS) duration and cardiac output measured by ventricular outflow tract velocity time integral (LVOT VTI) as a predictor of response in patients with CRT implantation.Methods:We studied 100 consecutive patients prospectively with biventricular pacing system. The patients were studied at the pacemaker follow-up clinic. Each patient was subjected to: Full medical history, general and local examination, a 12 lead electrocardiogram and QRS duration in ms was measured. All patients were subjected to a focused transthoracic echocardiographic examination in which a parasternal long axis view was obtained to measure the diameter of the LVOT diameter in mid-systole. The LVOT VTI was measured by pulsed-wave Doppler in the LVOT using a 2-mm sample volume positioned just proximal to the aortic valve in the apical five chamber view.Results:We found a statistically significant difference between CRT responders and nonresponders as regards age, body surface area (BSA), time since CRT implantation and smoking status (P = 0.018, 0.039, 0.002, <0.001). There was negative significant correlation between QRS duration and LVOT VTI and stroke volume index. The optimal cut off values for optimal response to CRT using receiver operating characteristics curves were 130 ms for postimplant QRS duration and 17.1 cm for LVOT VTI. We also found a significant difference between responders and nonresponders as regard CO. It was higher in responders (5.97 vs. 3.34, P < 0.001).Conclusion:CRT response is more in patients with lower BSA, and without previous history of ischemic heart disease or smoking. There is a significant negative correlation between QRS duration and LVOT VTI.

Tobacco smoking is an independent factor associated with retinal damage in systemic lupus erythematosus: a cross-sectional and retrospective study.

To analyze the influence of tobacco smoking on systemic lupus erythematosus (SLE) clinical features and damage. Cross-sectional and retrospective, case-control study comparing SLE patients with and without tobacco exposure. Cumulative clinical data and comorbidities were collected, and severity (Katz index) and damage (SLICC/ACR damage index) (SDI) indices were calculated. Pack-years (PY) was used to estimate lifetime tobacco exposure. A logistic regression was carried out to explore the impact of tobacco use on retinal damage. 216 patients were included. The mean age was 49years (± 12.7), 93% were females, and median disease duration was 17years [interquartile range (IQR):9-25]. Fifty-three percent of patients were smokers at some point. The median PY was 13 (IQR: 6-20.5). Only 54.8% of active smokers recalled having been informed of the negative effects of smoking, versus 83.3% of never smokers (< 0.001). In a bivariant analysis, an association between tobacco use at any time and discoid lupus [OR: 3.5(95%CI 1.5-8.9); p = 0.002] photosensitivity [OR: 2.06(95%CI 1.16-3.7); p = 0.01] and peripheral arteriopathy (p = 0.007) was found. Considering SDI item by item, a significant association with retinal damage, adjusted for age [OR: 1.03(95%CI 1-1.07); p = 0.04], was found. Using PYs, an association was found with discoid lupus (p = 0.01), photosensitivity (p = 0.03) and peripheral arteriopathy (p = 0.01), global SDI > 0 (p = 0.002) and retinal damage (p = 0.02). In a multivariate analysis exploring factors associated with retinal damage, any previous smoking history and SDI remained associated with retinal damage. Tobacco smoking is associated with cutaneous manifestations and damage and is an independent predictor of retinal damage in SLE patients.

Metastatic Lymphoepithelioma-like Carcinoma Treated with PD1-Antibody:Is Epstein-Barr Virus Eradication the Main Mechanism in 2 Refractory Cases in Children?

Background: Lymphoepithelioma-like carcinoma (LELC) is a rare high-grade carcinoma that can occur throughout the body. It is usually associated with Epstein-Barr virus (EBV) infection in patients from Asian countries. Pulmonary LELC occurs mostly in Asian women,, in their fifth or sixth decade, with no previous history of smoking. Optimal treatment has not been clearly established. Treatment options are based on surgery for early stage and on multimodal therapy for advanced stages.There is no report on children treated with programmed cell death 1 (PD1) inhibitor. Case Description: Case 1, a 12-year-old female who was admitted for cough and serious neck swelling. PET-CT showed multiple lymph nodes enlargement in the whole body ;among them, the anterior mediastinal lesions were fused with each other and the boundary between adjacent large vessels was unclear; multiple lung and pleural metastasis . EB virus in blood was 7.48×104copies/mL.Bone marrow morphology: Naive lymphocytes account for 2.5%, some lymphocytes are irregular; Mature plasma cells easy to see.Bone marrow immunotypes: 0.56% CD19-CD5-CD10-abnormally mature B lymphocytes. Biopsy: (left neck lump) LELC, EBERs(+).Partial remission was achieved after 2 courses of paclitaxel / carboplatin/ apatinib protocal. Due to delay with varicella, the tumor came back. After the third course of treatment,she showed chest tightness and pleural effusion, EB virus in blood increased, PDL1 protein was TPS 80% positive. After one PD1 antibody combined with chemotherapy,lymph nodes and thoracic lesions significantly reduced (Image1-3), blood EB virus turned to negative. She is now continuing with PD1 inhibitor. Case 2 , 10-year-old boy with huge right mouth bottom and right neck mass was diagnosed as LELC with EBER(+), TP53 (3%, +), CMYC (80% +). After chemotherapy, surgery and radiotherapy,he achieved complete remission. However, multiple metastases in mediastinum lymph nodes, pleura and lung happened and surgery, chemotherapy followed by automatic stem cell transplantation and pulmonary radiotherapy were given. CT-led puncture biopsy of suspected pulmonary residual lesion showed chronic inflammation with the mild growth of the alveoli, no malignant tumor.The child took oral Tegafur as maintenance regimen. 2 months later, recurrence appeared in lymph nodes, lung ,pleural and acetabular with positive EB virus in pleural effusion. Gene detection with NGS, which includes 312 gene-wide exon region, 208 gene hotspots and 16 fusion genes, did not show mutations such as gene mutations, amplification, and fusion with a clear clinical correlation. Tumor mutation load (TMB) was low, however,the boy had attained good response after PD1 antibody followed by rescue regimen and negative blood EB virus .The 2 patients didn't develop side effects correlating with PD1 inhibitor. Conclusion: To our knowledge, this is the first report of the use of PD1 inhibitor in children with metastatic LELC. These 2 refractory cases were all Epstein-Barr virus (EBV)-driven LELC,are more likely to respond to PD-1 blockade regardless of PD1 expresssion or TMB. EB virus burden disappeared after PD1 blockade,which perhaps can explain the anti-tumor effect.More cases are needed to verify the potential benefits of PD1 inhibitors to treat refractory LELC in children. Figure Disclosures No relevant conflicts of interest to declare.