Prior To Admission Research Articles

523 Weight Loss in Patients with Large Burns

Abstract Introduction The deleterious effect of weight loss in those with burns is well known. However, guidelines for monitoring loss are limited. This descriptive study evaluated weight loss incidence in patients with large burns admitted to a regional burn center. Methods Medical records for adult patients admitted to a regional burn center (2019-2021) with burns ≥20% total body surface area burned (TBSA) were reviewed. Patients with amputations were excluded. Data collection included burn size/depth, resuscitation fluids (pre- and post-admission), initial and final weight (last week of admission) and nutritional interventions. Patients were divided into three groups based on %TBSA: 20-29%, 30-39% and ≥40%. Results From 2019-2021, 722 patients with new burn injuries were admitted of whom 542 were over 18 years of age. Fifty-two (94% male) met inclusion criteria. Those with smaller burns had fewer surgeries and shorter stays. (Table 1). Most patients (85%) received resuscitation fluids prior to admission (PTA) with an average of 2782 mL PTA and a total of 21,079 mL after admission. Larger burns received high resuscitation volumes both pre- and post- admission. Over half of patients lost weight though 23 had a net weight gain. Most patients (56%) lost some weight but nearly half (48%) discharged within 5% of admission weight. The average loss across all groups was only 2.6% of admission weight (Table 2). Patients with larger burns were more likely to lose weight and also had more weight loss. Almost all (94%) patients required enteral nutrition and all transitioned to full oral intake prior to discharge; no one required parenteral nutrition. Again, patients with larger burns required more enteral intake. Conclusions Most patients lost weight though some had net weight gain. Those with larger burns lost more weight than those with smaller burns. Weight loss is a risk factor for malnutrition even with nutritional support. Weight loss in burn patients should be monitored—particularly in those with burns >30% TBSA--and be considered as an outcome measure in burn care. Applicability of Research to Practice Weight loss in burn patients should be monitored and considered as an outcome measure in burn care.

Validation and evaluation of a prior‐to‐admission medication list discrepancy risk‐scoring tool

AbstractIntroductionMedication reconciliation is vital in preventing medication errors during transitions of care. Implementation of effective medication reconciliation, however, remains a challenge for healthcare systems due to cost and resource constraints. The objective of this study was to evaluate a risk‐scoring tool for identifying patients at high risk for medication discrepancies and, therefore, prioritize pharmacy intervention with obtaining an admission medication history.MethodsSingle‐center validation study at an academic medical center including adult patients with a medication history note written by a pharmacy staff member. The primary outcome was the number of changes made to the prior‐to‐admission (PTA) medication list by pharmacy staff. Secondary outcomes included changes in risk score after medication history was completed, the number of changes based on disease state and medication class, and the number of clinically relevant changes for a randomized subgroup of patients.ResultsThe study included 12 122 patient encounters. The median PTA risk score was 29 (low risk), and 41% of patients were aged 40–65 years. The median number of discrepancies was higher for the high‐risk group (6, interquartile range [IQR] 3–11) compared to the low‐risk group (3, IQR 1–7), p < 0.001. For the primary outcome, Pearson's correlation coefficient was 0.37, indicating a weak correlation between the PTA risk score and the number of changes to the medication list. The linear regression also indicated a weak correlation (R2 = 0.14). Parkinsonism, diabetes mellitus, chronic obstructive pulmonary disease, and cystic fibrosis were associated with a higher median count of medication discrepancies.ConclusionsThis study demonstrated that this PTA medication risk‐scoring tool could help identify patients at high risk of medication discrepancies, but the score did not correlate well with the number of medication list changes. Therefore, subgroup analyses and further studies are needed to determine the optimal medication list risk‐scoring tools.

Abstract 15880: Detection of an Acute Pulmonary Embolism in the Home Bed Using Adherence-Independent Home Monitoring

Acute pulmonary embolism classically presents with dyspnea, tachypnea, and hypoxia, but self-recognition of symptoms and clinical findings is often challenging. This is particularly true in elder patients or those with cognitive impairments. Digital health technologies offer opportunities to remotely detect pre-symptomatic illness. We present a prodrome of an acute pulmonary embolism as it emerges in the home during continuous respiratory monitoring using a non-contact adherence-independent home bed sensor. The patient is an 85-year-old woman who is morbidly obese, has limited mobility, and multiple comorbidities including a recent diagnosis of atrial fibrillation for which she was prescribed anticoagulation but has not yet initiated. As part of an observational study, nocturnal respiratory rates (NRR) were longitudinally monitored in her home bed using a non-contact, adherence-independent bed sensor. Eight days prior to admission, increasing NRR prompted a patient call to family who noted no acute symptomatic changes. During the call it was discovered she had not been started on apixaban. On subsequent days, persistently elevated NRR prompted a second phone call 4 days prior to admission (PTA), where again no acute symptoms were noted. Anticoagulation still had not been started at that time. NRR worsened further on days following the second call prompting a home visit by an RN who found the patient dyspneic, tachypneic in the high 20s, and hypoxic with oxygen saturations in the 80s, prompting a transfer to the emergency department for further evaluation. She was eventually diagnosed with an acute pulmonary embolism. After a week-long hospitalization, the patient was discharged on adequate anticoagulation therapy.This case suggests that adherence-independent home bed monitoring of nocturnal respiratory rate may enable early detection of chronic volume overload and acute pulmonary embolism, potentially facilitating early intervention.

Pharmacist impact on medication reconciliation of behavioral health patients boarding in the emergency department.

IntroductionThe high demand for psychiatric services has exceeded the capacity of available resources for behavioral health patients, forcing these patients to seek mental health care in the emergency department. Average lengths of stay for behavioral health boarders commonly extend over multiple days and prior-to-admission (PTA) medication administration may be delayed, which could lead to further deterioration and longer inpatient lengths of stay. Addition of a pharmacist-led medication reconciliation process and pharmacist integration into daily emergency department psychiatry rounds may decrease time to initiation of PTA medications and improve outcomes in this population.MethodsThis is a retrospective review of adult patients who required a psychiatric emergency evaluation in a large rural academic medical center emergency department. Objectives were to determine the number and type of medication discrepancies found with pharmacist intervention, and to compare time to initiation of PTA medications with a pharmacist versus a nonpharmacist completing medication reconciliation.ResultsA total of 139 patients were identified, 85 patients in August 2019 (no pharmacist [NP]) and 54 in October 2019 (pharmacist involvement [PI]). Among 484 medications reviewed in the PI group, 298 discrepancies were identified. The most common types of discrepancies were no longer taking (n = 99, 33%) and omission (n = 94, 32%). Time to administration of PTA medications was similar between NP and PI groups (median hours, interquartile range: NP: 10.8, 7.8-16.57; PI: 11.49, 6.16-16; P = .179).DiscussionThis study depicted one of the many values of pharmacists in the hospital setting, especially in the behavioral health patient population where continuation of accurate PTA medications may prevent further clinical deterioration.

Polypharmacy and medication related falls risk in orthogeriatric femoral fracture patients Polypharmacy and medication related falls risk in orthogeriatric femoral fracture patients

Aim: To reportpolypharmacy rates and identify specific medications that increase falls riskin orthogeriatric femoral fracture patients. Method: A retrospectivesub-analysis, using the electronic medical records of patients admitted with a minimaltrauma femoral fracture to a tertiary teaching hospital during a 12-monthperiod was undertaken. Specific medications associated with falls risk wereclassified under three specific groups: benzodiazepines, tricyclicantidepressants (TCAs), and non-benzodiazepine hypnotics. Results: A sample of 131patients was included in the audit. Of these, 99 patients (75.6%) were reportedto be taking five or more medications prior to their falls related admission.From this, 49 patients (37.4%) were taking ten or more medications. One in fivepatients were found to be taking specified falls risk medications prior toadmission, primarily benzodiazepines (75.8%). Conclusion: Orthogeriatricpatients admitted to hospital with a femoral fracture following a minimaltrauma fall were commonly taking five or more medications prior to admission.Over a third of patients that were reported to take ten or more pre-admissionmedications were taking specified falls risk medications. This highlights theneed for medication-reviews and de-prescribing, particularly focusing on fallsrisk medications, to reduce incidence of falls and minimal trauma fractures inhigh risk patients

Computer Algorithms Support Physician Decisions in Traumatic Head Injury.

Computer Algorithms Support Physician Decisions in Traumatic Head Injury.

Evaluation of denosumab in adult oncology patients for the prevention of skeletal related events across a large academic health system.

Denosumab (Xgeva®) and zoledronic acid (Zometa®) are widely utilized for prevention of skeletal related events (SREs) in oncology patients. Drug costs, renal function, ease and logistics of administration, and adverse effect profile are factors frequently considered by patients and/or providers when selecting an optimal agent. Given the significantly higher drug cost of denosumab compared to zoledronic acid, an evaluation of our institution's denosumab use and investigation into opportunities to shift denosumab administrations to zoledronic acid and/or to lower cost sites-of-care was warranted. A single-center, multi-site, retrospective, observational analysis of the electronic medical record (EMR) was conducted for adult oncology patients who received denosumab 120 mg for prevention of SREs from October 1st, 2018 to September 30th, 2019 at three institutions within our health system. Additional information was collected to characterize the patient population based on cancer diagnosis, renal function, and concomitant calcium and vitamin D supplementation. Our primary objective was to evaluate if the use of denosumab met current formulary restrictions of the health system. In total, 304 adult oncology patients received 1411 doses of denosumab for the prevention of SREs. The majority of reviewed patients had a primary oncology diagnosis of breast (35%) or lung (24%) cancer. Of the patients who received denosumab, 278 (93%) met the health system's current formulary restrictions. The majority of patients who did not meet formulary restrictions were those with multiple myeloma (MM) (20/22; 91%). Of the 304 patients reviewed, 70 had the appropriate parameters in the EMR to calculate creatinine clearance (CrCl) using Cockcroft-Gault Equation. Of those 70 patients, 59 (84%) would have been eligible to receive zoledronic acid instead of denosumab given that their CrCl >30 mL/min with no documented intolerance to bisphosphonates. Concurrent use of calcium and vitamin D is recommended when using denosumab. Based on the most recent prior to admission (PTA) medication list obtained from the 304 patients evaluated, 222 (73%) had both calcium and vitamin D listed as "taking". Within our health system, denosumab is restricted to those who meet formulary restrictions. Additional education is recommended to help limit the use of denosumab, specifically in MM, to reduce drug costs when zoledronic acid is also an appropriate first-line agent.

Evaluation of the safety and tolerability of spironolactone in patients with heart failure and chronic kidney disease.

Spironolactone reduces morbidity and mortality in patients with heart failure (HF) with reduced ejection fraction (EF) and decreases hospitalizations in HF with preserved EF. To minimize the risk of hyperkalemia, patients must have an estimated glomerular filtration rate (eGFR) > 30mL/min/1.73m2 and potassium < 5.0mEq/L prior to initiation; however, spironolactone is prescribed outside these parameters. The objective of this study was to evaluate the safety and tolerability of spironolactone in patients with HF and chronic kidney disease (CKD). This single-center, retrospective cohort study evaluated patients ≥ 18years with HF and CKD stages 3-5 who received ≥ 48h of spironolactone therapy and were hospitalized from February 2018 to August 2019. The primary outcome was incidence of hyperkalemia (potassium ≥ 5.5mEq/L). Overall, 121 patients were evaluated: 52.1% (n = 63) had an EF > 40% and 47.9% (n = 58) had an EF ≤ 40% with 69.4% (n = 84) CKD stage 3, 24.8% (n = 30) stage 4, and 5.8% (n = 7) stage 5. Spironolactone was initiated prior to admission (PTA) for 54.5% (n = 66) of patients, while 45.5% (n = 55) of orders were initiated during hospitalization. Eight patients (6.6%) experienced inpatient hyperkalemia-all with PTA spironolactone. Patients who experienced inpatient hyperkalemia had a numerically lower eGFR that was not statistically significant (35.40 vs. 38.22mL/min/1.73m2; p = 0.730). Patients with CKD stage 3 (n = 4) had numerically higher rates of inpatient hyperkalemia than stages 4 (n = 1) or 5 (n = 3) (50%, 12.5%, and 37.5% respectively; p < 0.05). Spironolactone may be safe to initiate in hospitalized patients with HF and CKD; however, appropriateness of therapy must be assessed upon admission to the hospital. Larger studies are needed for conclusive results.

Assessment of a pharmacy technician medication history program.

To determine the percentage of unintentional prior-to-admission (PTA) medication list discrepancies captured by second-source verification. A prospective, randomized, controlled intervention was conducted on all patients admitted to a large academic medical center with a PTA medication list completed by a pharmacy technician from December 2018 through January 2019. Excluded patients included those admitted as observation status or discharged prior to the time of second-source verification. The following data was collected: patient's medical record number, age, admission date and time, service admitted to, date and time of completed PTA medication list, date and time of second-source verification, type of second-source verification, medication name, dose, route, frequency, formulation, and confidence level of pharmacy technician completing the initial PTA medication list. Second-source verification was conducted on all medications from a patient's PTA medication list after completion by a pharmacy technician. There were a total of 992 medications from the 200 randomly assigned patients with a completed PTA medication list by a pharmacy technician during the study time frame. Of these medications, 116 (11.7%) contained a discrepancy identified by second-source verification. The most common type of discrepancy was omission (67%) followed by dosing, frequency, and formulation. The median time to complete second-source verification was 9 minutes (interquartile range, 5-17 minutes). Second-source verification at the time of hospital admission helps identify medication discrepancies and may improve medication use safety and prescribing pattern and, accordingly, may contribute to reducing medication errors.

MYELODYSPLASTIC SYNDROME PRESENTING AS CENTRAL DIABETES INSIPIDUS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Central diabetes insipidus (CDI) is characterized by a decreased release of antidiuretic hormone (ADH) and often caused by disorders that act at sites involved in either ADH secretion or delivery. Common causes of CDI include primary/secondary brain tumors, infiltrative diseases, trauma, and idiopathic CDI. Non-traumatic causes of CDI are less studied. Myelodysplastic syndrome (MDS), which describes a group of hematopoietic stem cell disorders that is characterized by dysplasia and cytopenia, is a rare but reported non-traumatic cause of CDI. We present a patient with a history of MDS that was found to have CDI during his hospital course. CASE PRESENTATION: A man in his 60s, with history of relapsed acute myeloid leukemia with induction chemotherapy one month prior to admission (PTA), presented with one week history of fevers and melena. Stated he had been urinating several times a day, with at least two episodes of nocturia, and severe thirst. Patient denied headache, nausea, vomiting, or trauma. On presentation, he was mentating well with dry mucous membranes. His initial sodium (Na) levels of 141 mEq/L increased to 160 mEq/L after two liters (L) of normal saline (NS) resuscitation, peaking at 164 mEq/L. Urinalysis revealed specific gravity of 1.006 when Na was 148 mEq/L. His urine osmolality became more concentrated with desmopressin (DDAVP) administration, increasing from 192 mOsm/kg to 381 mOsm/kg, suggestive of central diabetes insipidus (DI) over nephrogenic. Daily urine output progressed from 5.7L to 2.6L to 0.65L. MRI brain was negative for sella or pituitary findings. His Na levels improved to normal limits with DDAVP and 1/2 NS. Patient received a bone marrow cancer karyotype one year PTA, which revealed a t(6;16), (p21;q24) chromosome abnormality. DISCUSSION: There are three leading mechanisms for CDI as a complication of MDS: DNA methylation, chromosomal abnormality, and micro-infiltration of cancer cells. In a study of 184 patients with MDS and AML, DNA methylation microarray was used to assess the relative contributions of aberrant DNA methylation during disease progression and was notably seen in every case. With alterations of the mRNA-expression and promoter-related DNA methylation of vasopressin, particularly ANP precursor genes, as a pathophysiologic mechanism for CDI, DNA methylation is noted to be involved in both processes. Regarding chromosomal anomalies, the most common associated with MDS and CDI are 2,3,7,12, and 20. Our patient had a balanced translocation between the short arm of chromosome 6 and the long arm of chromosome 16. To our knowledge, this is a novel finding that warrants further research. Lastly, reported micro-infiltration of cancer cells to the hypothalamus leading a presentation of CDI have been documented. CONCLUSIONS: CDI should be considered in all AML/MDS patients presenting with polyuria and polydipsia with an unremarkable MRI of the brain. Reference #1: Jiang, Y., Dunbar, A., Gondek, L. P., Mohan, S., Rataul, M., Okeefe, C., … Maciejewski, J. P. (2009). Aberrant DNA methylation is a dominant mechanism in MDS progression to AML. Blood, 113(6), 1315–1325. doi: 10.1182/blood-2008-06-163246 Reference #2: Sun, R., Wang, C., Zhong, X., & Wu, Y. (2016). Diabetes Insipidus as an Initial Presentation of Myelodysplastic Syndrome: Diagnosis with Single-Nucleotide Polymorphism Array-Based Karyotyping. The Tohoku Journal of Experimental Medicine, 238(4), 305–310. doi: 10.1620/tjem.238.305 DISCLOSURES: No relevant relationships by Narjes Akhlaghi, source=Web Response No relevant relationships by Rohit Aloor, source=Web Response No relevant relationships by sai phani sree cherukuri, source=Web Response

Pain in Inflammatory Bowel Disease Is Not Improved During Hospitalization: The Impact of Opioids on Pain and Healthcare Utilization

Most patients with IBD experience pain, especially during acute disease exacerbations. Opioid use continues to be more prevalent in IBD than any other chronic gastrointestinal condition, and the majority of IBD patients consume narcotics during hospitalization despite the risks of infection and death. We performed a retrospective review of 57 subjects aimed at quantifying pain and opiate consumption for IBD-related admissions over a 3-month period. For each patient, the average and maximum of each day's pain scores were used to measure changes in pain from admission to discharge using mixed model regression, with opiate use as a time-dependent covariate. The daily average pain score over the entire hospitalization was 4.23 ± 2.09, and the maximum pain score was 8.28 ± 1.75. Among opioid users (n = 51), the daily average pain score was 4.65 ± 2.16 and the maximum pain score was 7.53 ± 2.56. Across all cases from admission to discharge, there was less than a 1-point change in daily average pain (- 0.96 ± 2.03, p = 0.0009), and no change in maximum pain (- 0.89 ± 3.59, p = 0.0671). Opioid users, a subset of the overall cohort, had a similar less than one-point drop in daily average pain (- 0.94 ± - 0.29, p = 0.0024) and no change in daily maximum pain scores (- 0.81 ± - 0.47, p = 0.0914). Patients on average used 20 ± 25mg morphine equivalents per day. Opioid-naïve patients used similar doses to those who used opioids prior to admission (PTA). Almost half of all cases (47%) were discharged with an opioid prescription, the majority (71%) of whom were not on opioids PTA. Pain in IBD is not well controlled through hospitalization, with less than a 1-point change from admission to discharge, despite significant opioid consumption. Alternative analgesic methods should be explored, given the significant impact of narcotics on long-term outcomes including mortality and quality of life.

Seorang Wanita Muda dengan Tuberkulosis Usus Menyerupai Apendiksitis Akut

Background: Tuberculosis has become a global health problem, with increasing numbers of cases in line with the increasing number of immunocompromised patients. Intestinal of tuberculosis is believed to be a form of extrapulmonary tuberculosis which will occur most often in the future . Case: This case presents a young woman, 20 years old, suspected of acute appendicitis with suspected perforation, had right abdominal pain since 1 month and getting worse since 5 days PTA (prior to admission). The abdomen enlarges and feels hard on the right abdomen after being treated for 3 days. Fever,body weaknes,decreased of appetite, decreased of body weight approximately 7 kg since 2 months PTA. There are nausea, vomiting, diarea with runny mucus since 2 weeks PTA. The chest x-ray, abdominal ultrasound, endoscopy was normal result and plain abdominal radiograph showed that intestinal dilatation and step ladder features suspicious obstructive ileus. Discussion: After 2 months of therapy abdominal symptoms improved and weight began to gradually increase. Intestinal of tuberculosis is a challenge for clinicians to diagnose despite using modern medical techniques because the clinical and laboratory features are not specific especially when active pulmonary infection is absent and there are similarities with other abdominal diseases. The histological features will provide a diagnose. The delay in diagnosis will lead to more severe complications. Conclusion: At present a combination of clinical, radiological and pathological features continues to be the key to diagnosing intestinal tuberculosis. Medical management with antituberculosis drugs will produce a significant resolution of symptoms.

Renal actinomycosis - a case report

Introduction. Actinomycosis of the urogenital tract mainly manifests with formation of renal and perirenal abscesses. When it comes to treating renal lodge abscesses caused by Actinomyces bacteria, the method of choice is mainly surgical evacuation of purulent collections, followed by administration of parenteral penicillin or cephalosporin antibiotics during a six week period. The definitive diagnosis is made based on the antibiogram findings, isolation of Actinomyces israelii from abscess collection, as well as by characteristic histological findings. The exact incidence and prevalence of urogenital actinomycosis is still unknown. Case Report. A 54-year-old female patient was admitted to the Emergency Department of the Clinical Center of Vojvodina for triage. She complained of pain in the left lumbar and gluteal region, weakness, malaise, and fever. She was treated with corticosteroids under the diagnosis of vasculitis five months prior to admission. Based on clinical, laboratory blood and urine tests, ultrasound examination of the abdomen and contrast CT of the abdomen and pelvis, the diagnosis of left kidney abscess was made. It also spread to the retroperitoneum (iliopsoas muscle, gluteus maxuimus and ipsilateral inguinal region). Urgent operative exploration of retroperitoneum and kidney was performed. A lumbotomy was performed in the left half of the retroperitoneum with evacuation of abscesses, as well as partial nephrectomy of the lower half of the left kidney. Subsequently, the obtained antibiogram of operatively sampled aspirate, renal actinomycosis was histopathologically verified. The surgically removed tissue that was sent for histopathology showed presence of connective tissue infiltrated with a pronounced inflammatory infiltrate composed of lymphocytes, plasma cells, histiocytes and granulocytes with numerous microabscesses and actinomycosis colonies.

Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes &gt; 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p&lt;0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes &gt; 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

First report of mesalamine (5-aminosalicylic acid) as the causative agent in a case of acute generalized exanthamous pustulosis

Acute generalized exanthamous pustulosis (AGEP)is a rare eruption of non-follicular sterile pustuleson a diffuse background of erythema and edema,commonly associated with fever and leukocytosis.Antibiotics are implicated in most cases; however,other drugs have been reported to cause AGEP. Wereport a case of a 73-year-old man with a historyof ulcerative colitis who presented with a diffusepustular rash, renal failure, elevated liver functiontests, and leukocytosis with neutrophilia. A week priorto admission, the patient was started on mesalamineto treat colitis. Upon admission, a workup includinga skin biopsy was performed and was consistentwith AGEP. Mesalamine was discontinued, and thepatient's skin eruption, renal function, liver functiontests, and leukocytosis subsequently improved.Mesalamine has an unknown mechanism of action.However, it is thought to be an anti-inflammatoryagent that blocks the production of leukotrienesand prostaglandins and is an immunosuppressantthat increases the release of adenosine, whichinterferes with leukocyte function. The decrease inprostaglandin synthesis or deregulation of leukocytefunction caused by mesalamine may be the etiologyin this case. Discontinuation of the offending agentleads to resolution of AGEP, as it did in this patient.

Confounding Presentation of Small Bowel Ischemia in an IBS Patient and Diagnosis and Treatment Utilizing CO2 Angiography: New None-nephrotoxic Diagnostic Modality

Introduction: Mesenteric ischemia is a difficult diagnosis to make but should be considered in older patients with weight loss. Since, CKD is a common comorbidity in patients with vascular disease contrast agents may contraindicated. CO2 angiography is a non-nephrotoxic alternative to vascular intervention. Case: The patient is a 90 year old female with a 40 year history of functional dyspepsia and IBS - diarrhea. 1 year PTA (prior to admission) she began noting vague post-prandial epigastric discomfort relieved with belching and probiotics. 9 months PTA, she noted early satiety and nausea following greasy food ingestion resulting in decrease intake and a 20lbs weight loss. Malignancy work-up (EGD, colonoscopy, CT abdomen/pelvis without contrast because of ↓ GFR, standard lab work) were negative except for marked atherosclerosis of the aorta and a small benign antral ulcer. She was treated with PPI and sucralfate. 7 months PTA, repeat EGD revealed another, small clean based antral ulcer at a different site with negative histology. She had now lost 40 lbs. with a BMI of 20. She attributed her weight loss to severe siderophobia as her postprandial epigastric pain occurred 20 minutes following meals with an intensity of 7-9/10, lasting 2-3 hours. She was also noted to have a retinal artery occlusion possibly 2nd to an atheromatous plaque which alerted us to the possibility of mesenteric ischemia. PE: Significant abdominal bruit. A CTA or MRA could not be performed because of her CKD.Figure 1Figure 2She was referred to vascular surgery who performed a Doppler US noting a >70 % stenosis of the SMA. Because of her CKD, she underwent CO2 angiography which identified a 90-99% stenosis of the SMA. After 6 hours, the SMA was catheterized and a stent was placed across the stenosis resulting in >50% flow. She had immediate and complete symptom relief. After 6 months, she had gained 20 lbs. Discussion: Mesenteric ischemia can present insidiously at first with vague, non-specific symptoms. When this is combined with a history of well-established functional GI disease, further delay in diagnosis can occur. Therefore, a high suspicion for the diagnosis of mesenteric ischemia is necessary and any new symptoms in a functional disease patient should be followed closely. For patients with CKD, CO2 angiography with digital subtraction angiography (DSA) is a preferred alternative to contrast angiography for treatment of mesenteric ischemia. This technique, which is relatively unknown to radiologists, is a therapeutic advance which few gastroenterologists recognize. It is a new armamentarium that can be used in older patients with poor kidney function. Further discussion and Illustrations of CO2 angiography will accompany the abstract.

P3-31-1 - Pulmonary Artery Sarcoma Masquerading as Pulmonary Embolism and Infection: a Case Report

A 61-year-old man with hypertension had developed exertional dyspnea for 2 years. His symptom got worse with fever and wet cough 4months prior to admission (PTA), and inspiratory pain on his right chest 3 months PTA. He was suspected of having an atypical pneumonia or a tuberculosis on CT. Enhanced chest CT showed large mural defects in right main pulmonary artery, clearly delineated by contrast medium.He was diagnosed as having a pulmonary embolism and received anticoagulation therapy with heparin followed by warfarin. Despite 1 week of warfarin therapy, he remained symptomatic with no change in the pulmonary artery filling defects on repeated enhanced CT.Pulmonary artery sarcoma, or a metastatic tumor were suspected of by its time course and accompanying symptoms and signs of fever, secondary anemia, and weight loss. Increased uptake of FDG in the affected pulmonary artery indicated that pulmonary artery sarcoma was most likely.Aspiration cytology and needle biopsy through pulmonary artery catheter revealed malignant cells with results of CD31(-), CD34(-), D2-40(+),α-Actin(-), and AE1/AE3(+), consistent with pulmonary artery sarcoma which was not able to be specified further.It was out of operative indication because of distant metastasis in his lungs. Therefore, he received weekly Paclitaxel(45mg/m2) + Carboplatin(AUC 2)concurrent with TRT 60Gy/30Fr in order to mainly control intra-arterial mass. However, we discontinued it at 6courses because of neutropenia(Gr3) and development and progression of non-tuberculosis mycobacterium infection. He was also intolerable to pazopanib due to many side effects of increasing in the liver enzymes(Gr1), hypertension(Gr3), anorexia(Gr3), diarrhea(Gr3), nausea(Gr3) and NTM exacerbation. On the other hand, his primary and metastatic lesions have a tendency to decrease in size in comparison with one before chemotherapy. We will report this case with literature review in terms of diagnostic difficulty of pulmonary artery sarcoma.

Lepromatous leprosy mimicking systemic lupus erythematosus: a clinical pathology conference held by the division of rheumatology at hospital for special surgery.

Keywords leprosy.anthiphospholipidantibodyCase PresentationA 29-year-old Brazilian woman was referred for manage-ment of systemic lupus erythematosus (SLE) withantiphospholipid antibodies (aPL). Her symptoms were1 year of intermittent fever and diffuse, tender, erythe-matosus, and nodular rash that began during her firstpregnancy. She was treated with short course of low-dose corticosteroids, with resolution; however, she suf-fered an embryonic loss at 7 weeks. Six months prior toadmission, she had recurrence of the nodular rash withnew onset arthralgia; a skin biopsy showed panniculitis.Tests done at that time showed lupus anticoagulant(LA), anticardiolipin antibody (aCL) IgM >150 U (nor-mal 0–7 U), anti-β

Reversible posterior leukoencephalopathy syndrome

A 40-year-old woman presented with headache, lethargy,dysarthria, diplopia and altered mental status. Her pastmedical history was significant for cystic fibrosis for whichshe underwent bilateral lung transplantation 3 years priorto admission. Her medications included tacrolimus andprednisone. On physical examination, she was afebrile andnormotensive without neck stiffness; she was intubated andon mechanical ventilation. Her MRI brain with intravenousgadolinium showed symmetric hyperdense signals withinthe white matter involving parietal (Fig. 1a), occipital(Fig. 1b) and cerebellar regions (Fig. 1c), without intrace-rebral space-occupying lesions. Cerebrospinal fluid (CSF)studies revealed clear and colorless fluid with normalopening pressure, cell counts, glucose and protein. Evalu-ation for infections, including routine blood cultures, CSFGram’s stain and cultures, VDRL, cryptococcal antigen,cytomegalovirus (CMV) polymerase chain reaction (PCR)assay, Epstein–Barr virus (EBV) PCR, human herpes virus-6 (HHV-6) PCR and JC virus PCR, was, however, unre-vealing. Serum tacrolimus drug level was 5 ng/ml (normal5–20 ng/ml). The clinical diagnosis of tacrolimus-associ-ated reversible posterior leukoencephalopathy syndrome(RPLS) was entertained given the negative infectious dis-eases workup. Tacrolimus was cautiously tapered off overa week, and her neurological condition slowly improved.Repeat MRI brain imaging a week after complete discon-tinuation of the tacrolimus showed the resolution of thehyperintense lesions (Fig. 1d, e).RPLS, also known as posterior reversible encephalopa-thy syndrome (PRES), is a clinical syndrome of varyingetiologies, but with similar neuroimaging findings. Char-acteristic clinical manifestations include non-localizedheadache unresponsive to analgesics, altered mental status,visual disturbances and seizures [1, 2]. RPLS is frequentlyassociated with acute hypertension, preeclampsia oreclampsia, sepsis, renal failure, thrombotic thrombocyto-penic purpura, hypercalcemia, hypomagnesium, autoim-mune diseases, cytotoxic therapies andimmunosuppressants [2]. Because of widespread use ofcalcineurin inhibitors (cyclosporine and tacrolimus) inpatients with solid organ transplantation (SOT) to preventorgan rejection, neurotoxicity of these agents has beenincreasingly reported, although the incidence of RPLSamong patients with SOT is low (0.5 %) [3]. The under-lying pathophysiology of RPL is poorly defined. Hypoth-eses include cerebral ischemia from vasospasm, disorderedcerebral autoregulation and endothelial dysfunction [1, 2].RPLS associated with calcineurin is thought to result fromdirect toxic injury to vascular endothelium, leading toproduction of inflammatory cytokines and capillary leak-age, which triggers vasogenic cerebral edema [1, 3, 4].Hypertension and high serum tacrolimus level are com-monly associated with RPLS but there are reported RPLScases with normal blood pressure and normal serum ta-crolimus drug concentrations [5]. Brain MRI, particularlyfluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences, is the imagingmodality of choice of diagnosing RPLS. Typical MRIfindings are symmetrical white matter changes primarily

Anterior wall acute ST-segment elevation myocardial infarction probably due vasospastic occlusion of proximal left anterior descending artery: to stent or not to stent

A 35-year-old female patient, weight 54 kg, height 173 cm,BMI 18.0 was admitted to our PCI center for acute anteriorSTEMI. Routine myocardial necrosis marker CK 737, cTnT1.0 was positive. From cardiovascular risk factors; 15 ciga-rettes/a day and taking contraception pills. She was a pro-fessional handball player a few years ago and now occa-sionally plays handball in the Veterans League. 6 days priorto admission after the game, she felt retrosternal pain ex-tending into the epigastrium. The pain reoccurred on thenext day, the dyspepsia was diagnosed, she was hospita-lized in an outpatient clinic, underwent gastroscopy with ne-gative results. ECG was performed on several occasionswhich showed no abnormality detected. On the day of relo-cation, the pain reoccurred starting in the upper abdomenaccompanied with hypotension and ECG changes. We per-formed primary PCI which showed occlusion of high proxi-mal segment of the LAD without thrombus formation. RCAwas dominant with smooth walls with retrograde collateralsto LAD appearing only fragmentary. Acx hypoplastic alsowithout atherosclerotic changes. The guidewire was introdu-ced through the site of occlusion in LAD up to the apex andextensive balloon dilatation with different diameters was per-formed without success and with pronounced “recoil phe-nomenon”