Second Day Of Hospitalization Research Articles

Identification of Inflammatory Mediators in Saliva Samples From Hospitalized Newborns: Potential Biomarkers?

To characterize the levels of 11 inflammatory mediators (IFNg, IL1b, IL2, IL4, IL6, IL8, IL10, IL12, IL17, TNF, and VEGF) in saliva samples from NB on the first and second day of hospitalization in the Neonatal Intensive Care Unit (NICU). Exploratory study, descriptive, nested within a primary clinical, observational, and prospective study, conducted in the NICU of a public hospital in São Paulo, Brazil. Demographic data and vital signs were recorded in the clinical records of 90 NB, and five saliva samples from 5 NB were collected between the first and second day of life (D1-D2) at approximately 8-hr intervals (8-9 am, 4-5 pm, and 11-12 pm). Saliva samples were used for the measurement of 11 cytokines (IFNg, IL1b, IL2, IL4, IL6, IL8, IL10, IL12, IL17, TNF, and VEGF). Five NBs participated in this exploratory study, and the vital signs showed variability from the first (D1) to the second day (D2) of hospitalization, variability similar to that of the total population of the primary study. The presence and levels of the 11 cytokines were detected in the saliva samples, as well as a statistical correlation between 10 cytokines (IFNg, IL1b, IL2, IL4, IL6, IL10, IL12, IL17, TNF, and VEGF) and vital signs. The novelty of measuring inflammatory mediators in saliva samples from hospitalized NBs in the NICU is highlighted, providing support and new perspectives for the development of clinical and experimental research and an opportunity for developing and implementing new salivary biomarkers in different population segments.

Anemic Gastrointestinal Bleeding in Campylobacter Jejuni Infection

We present a 13-month-old male with a history of multiple diarrheal episodes with mucus and blood due to Campylobacter Jejuni infection. He was admitted in the last of them due to mucosanguinous stools, fever and oral intolerance. He was treated with amoxicillin/clavulanic acid and a blood test was performed without leukocytosis (14 x109/L) but with neutrophilia (10.2 x109/L) and elevated CRP (85mg/L), in addition to abdominal ultrasound with minimal fluid tab in the right iliac fossa. On the second day of hospitalization, he presented an anemizing and painless gastrointestinal bleeding that required transfusion (hemoglobin 6.3g/dL), however, he was hemodynamically stable, with slightly painful abdomen in lower quadrants, but without peritoneal irritation.

'Evaluation of beta-2-microglobulin and neuron-specific enolase as prognostic factors in patients over 65 years of age with frailty syndrome hospitalized for acute coronary syndrome'.

The aim of the study is to assess the value of beta-2-microglobulin (B2M) and neuron-specific enolase (NSE) as prognostic factors in the population of patients over 65 years of age with frailty hospitalized due to acute coronary syndrome (ACS). Patients aged ≥65 years with ACS were included. Assessment of frailty was carried out using the FRAIL scale. The measurement of NSE and B2M was carried out three times during hospitalization: (1) at the time of admission, (2) on the second day of hospitalization, (3) on the seventh day of hospitalization, or the day of discharge if it was before the seventh day. The primary endpoint was all-cause mortality, and the secondary endpoint was unscheduled rehospitalization. Of the 127 patients, frailty was identified in 39.3%. Multivariate analysis of variance showed significantly higher levels of NSE (P = 0.012) and B2M (P < 0.001) in patients with frailty compared to the nonfrail group and significant changes in marker levels during hospitalization - decreased NSE (P < 0.001) and increased B2M levels (P < 0.001). Elevated B2M-1 level was an independent marker of the occurrence of frailty [odds ratio (OR), 1.98 (1.09-4.00); P = 0.044], and the optimal cutoff point for the diagnosis of frailty was 2.85 mg/l [area under the curve (AUC), 0.718 (0.632-0.795)] with sensitivity 52% and specificity 84.4% (P < 0.001). Elevated NSE-3 level was associated with all-cause mortality, and each 1 ng/ml increase in NSE-3 increased the risk of death by 1.07-fold [OR, 1.07 (1.03-1.10]). Meanwhile, elevated B2M-3 level was associated with unscheduled rehospitalization, and each 1 mg/l increase in B2M-3 increased the risk of unscheduled rehospitalization by 1.21-fold [OR, 1.21 (1.03-1.42)]. The Harrell's C-index for all-cause mortality was higher for NSE-3 [0.820 (95% confidence interval {CI}, 0.706-0.934)] compared to frailty assessed by the FRAIL scale [0.715 (95% CI, 0.580-0.850)], which means that additional NSE-3 assessment may improve the prediction of all-cause mortality. However, Uno's C-Statistic analysis showed that the difference was not statistically significant (Pr>chi-square 0.556). Harrell's C-index for unscheduled rehospitalization was higher for frailty assessed by the FRAIL scale compared to B2M-3. Monitoring NSE and B2M marker levels in patients over 65 years of age with frailty and ACS does not provide additional benefits in terms of prognostic ability compared to tests assessing frailty. B2M, assessed upon hospital admission and monitoring NSE and B2M levels during hospitalization may be considered in the diagnosis of frailty and risk stratification in a group of patients for whom currently available frailty diagnostic tools cannot be used.

Severe neurological complications in a child with multisystem inflammatory syndrome in children after asymptomatic COVID-19

Introduction. Coronavirus disease-2019 (COVID-19) usually leads to a mild infectious disease course in children, but serious neurological complications have been described in association with both acute infection and the multisystem inflammatory syndrome in children (MIS-C). Cerebrovascular disorders (CVD) in children are rare complication of MIS-C, and various potential mechanisms of CVD in MIS-C have been hypothesized. Case outline. In an eight-year old girl, diagnosis of MIS-C was made according to clinical features of prolonged fever, circulatory shock, heart and renal insufficiency, skin abnormalities, conjunctival hyperemia, and stomach pain associated with laboratory findings (increased CRP, D-dimers, pro BNP, troponins, IL-6), supported by positive contact with SARS-CoV2 one month before the disease onset and increased IgG and IgM anti-SARS-CoV2 antibodies. From the second day of hospitalization, left-side hemiplegia was observed, and using brain CT and MR, CVD was diagnosed. Together with cardiovascular support, corticosteroids and intravenous immunoglobulin were administered. On the fourth day of hospitalization, diagnosis of cerebral salt wasting syndrome (CSWS) was made according to severe dehydration, polyuria, hyponatremia, increased natriuria, and increased urine: serum osmolality ratio. CSWS had very severe course lasting more than one month. The girl was discharged with stable vital signs, normal diuresis and hemiparesis. Conclusion. This is the first case in the literature presenting association of severe CSWS and CVD in a child with MIS-C after COVID-19.

Evidence-Based Care of Staircase Recruitment Maneuver in a Patient with Severe Acute Respiratory Distress Syndrome

&lt;p&gt;急性呼吸窘迫症是致死率很高的急症，嚴重呼吸困難會造成病人有瀕死的危象。筆者於2020 年11月照顧一位67歲男性因急性呼吸衰竭插管治療，對於肺保護通氣策略之效果不佳，甚至使用體外膜氧合維生系統仍嚴重低血氧，引發筆者想解決此醫療困境之動機。運用實證步驟探討階梯式肺再擴張術增加氧合能力之成效，以PICO詮釋臨床問題，P為急性呼吸窘迫症（Acute respiratory distress syndrome, ARDS）、I為階梯式肺再擴張術（Staircase recruitment maneuver, SRM）、C為常規照護（Usual care）、O為氧合能力（PaO2/FiO2 ratio, PFR），檢索Cochrane Library、PubMed、CINAHL和華藝線上圖書館等資料庫，最終納入五篇符合篩選標準之隨機對照試驗研究，經系統性回顧後再進行統合分析，共有1,229 位病人之資料進行統合分析，發現SRM可改善PFR增加氧合，其綜合效量為55.63（95%CI [44.92, 66.33]）。依據研究結果應用於個案，住院第二天在壓力控制模式下執行一次SRM，當驅動壓力15 cmH2O，呼氣末正壓從10 cmH2O開始調升，每40秒增加5 cmH2O，並追蹤個案之動脈血氧，其PFR由174上升至318 mmHg，最終成功脫離呼吸器。因此，建議使用呼吸器之ARDS病人，若肺保護通氣策略下仍有嚴重低血氧時，可以考慮執行SRM來增加病人的氧合，進而讓病人能盡早脫離呼吸器。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Acute Respiratory Distress Syndrome is a highly fatal emergency. Severe dyspnea could lead to a re-spiratory crisis. The author provided care for a 67-year-old man who was intubated due to acute respi-ratory failure in November 2020. The ventilation strategies for lung protection strategies (LPS) were not as effective as expected. Even when using the extracorporeal membrane oxygenation (ECMO) life support system, hypoxemia still presented and deteriorated rapidly. This incident gave the author the motivation to solve this medical dilemma. An evidence-based approach was adopted to assess the ef-fectiveness of the staircase recruitment maneuver for oxygenation. The clinical treatment using PICO interpretations are as follows P: Acute respiratory distress syndrome (ARDS), I: Staircase recruitment maneuver (SRM), C: Usual care, O: PaO2/FiO2 ratio (PFR). Databases such as Cochrane Library, PubMed, CINAHL, and Airiti Library were searched. Five randomized controlled trial studies that met the screening criteria were included, and a meta-analysis was conducted after a systematic review. A total of 1,229 patients were analyzed in the meta-analysis, which showed that SRM can improve PFR and increase oxygenation. The effect size was 55.63 (95% CI [44.92, 66.33]). According to the re-search results applied to this case, SRM was performed in pressure control mode on the second day of hospitalization. When the driving pressure was set at 15cmH2O, the positive end-expiratory pressure (PEEP) was titrated from 10cmH2O, increasing by 5cmH2O every 40 seconds. Tracing the patient&amp;rsquo;s arterial blood oxygenation, the PFR increased from 174 to 318 mmHg, and the patient was successful-ly weaned from the ventilator. Therefore, ventilators are recommended for ARDS patients with severe hypoxemia under LPS. SRM maybe considered to improve the patient&amp;rsquo;s oxygenation, allowing for ear-ly weaning from the ventilator.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Analisis Jumlah Trombosit Dan Leukosit Pada Pasien Dengue Hemorrhagic Fever (DHF) Di Rumah Sakit Umum Daerah Kabupaten Barru

Dengue hemorrhagic fever (DHF) is a chronic fever disease caused by infection with the dengue virus which is transmitted through the bite of the Aedes aegypti and Aedes albopictus mosquitoes. Laboratory abnormalities that are often found in DHF patients are thrombocytopenia and leukopenia. This study aims to determine the results of examination of platelet and leukocyte counts in dengue hemorrhagic fever (DHF) patients. This study used a descriptive design with the population being all dengue hemorrhagic fever (DHF) patients at the Barru District General Hospital. The sample consisted of 30 DHF patients whose platelet and leukocyte counts were checked using a hematology analyzer for 3 consecutive days of hospitalization. The sampling technique in this research is the purposive sampling method. The results of the study showed that there were 30 DHF patients consisting of 14 (47%) men and 16 (53%) women with the highest age found `DHF being 8 - 12 years old, 10 people (33.33%). On the first day of hospitalization, 29 people experienced thrombocytopenia and 1 person had normal platelets. On the second day of hospitalization, 25 people experienced thrombocytopenia and 5 people had normal platelets. On the third day of hospitalization, 11 people experienced thrombocytopenia and 19 people had normal platelets. On the first day of hospitalization, 17 people experienced leukopenia, 11 people had normal leukocytes and 2 people had leukocytosis. On the second day of hospitalization, 8 people experienced leukopenia and 22 people had normal leukocytes. On the third day of hospitalization, 3 people experienced leukopenia and 27 people had normal leukocytes. This study shows that the majority of DHF patients experience thrombocytopenia while the platelet count tends to be normal.

A Retrospective Comparative Study of the Effect of Controlled-Release Dinoprostone Vaginal Delivery System (Propess®) and Mechanical Methods for Cervical Ripening in Nulliparous Women in Late-Term Pregnancy.

The effects of the controlled-release dinoprostone vaginal delivery system (Propess®) and mechanical methods for cervical ripening in nulliparous women in late-term pregnancy were compared retrospectively. This retrospective comparative study included 46 nulliparous pregnant women (24 in the Propess®group and 22 in the mechanical methods groups) with a low Bishop score (≤1) who needed labor induction at 41 weeks of gestation. The primary outcome was the success rate of cervical ripening (= Bishop score >6 or vaginal delivery) by the next day following the insertion of Propess®only or mechanical cervical dilation only. In the cases in which cervical ripening was unsuccessful, other methods were performed, and the success rate of cervical ripening the day after was compared as the secondary outcome. As the primary outcome, there was not a significant difference in the success rate of cervical ripening between the Propess®and mechanical methods groups (21 vs. 22%, p = 0.88). As for the secondary outcomes, there was not a significant difference in the total success rate of cervical ripening between the two groups (75 (5+13/24) vs. 73 (5+11/22)%, p = 0.86)). Of the unsuccessful cervical ripening cases as secondary outcomes, the Bishop score of all was ≤2 on the second day of hospitalization. The combined use of Propess®and mechanical methods was effective for cervical ripening in nulliparous women with a low Bishop score in late-term pregnancy, regardless of order.

Fat embolism syndrome after humerus and pelvis fracture complicated by acute kidney injury requiring blood purification: a case report and literature review

BackgroundFat embolism syndrome (FES) is a rare syndrome that typically occurs 12–72 h after long bone or pelvic fractures with a classic triad of respiratory distress, neurologic changes, and petechial rash. Although Gurd’s criteria for FES include anuria or oliguria, the mechanism of acute kidney injury (AKI) remain unknown. Here, we present a case of FES complicated by AKI that required blood purification.Case presentationA 79-year-old woman was admitted to our hospital because of a right humerus and pelvic fracture caused by a traffic accident. On the second day of hospitalization, she developed impaired consciousness, respiratory failure, and disseminated intravascular coagulation (DIC). Chest radiography revealed bilateral diffuse alveolar infiltration. Brain magnetic resonance imaging revealed diffuse high signal intensity on diffusion-weighted imaging and diffuse low signal intensity on susceptibility-weighted imaging in the cerebral and cerebellar regions. The diagnosis of FES was confirmed and the patient was treated with methylprednisolone (40 mg/day) and ulinastatin. On the third day of hospitalization, she was admitted to our department because of AKI with oliguria. Although echocardiography showed an elevated right ventricular artery systolic pressure suggestive of pulmonary hypertension (PH), pulmonary congestion was initially considered on chest imaging, and hemodialysis and rapid ultrafiltration were initiated. However, she developed hypovolemic shock and treatment was switched to continuous hemodiafiltration and slow ultrafiltration. Thereafter, her consciousness, hypoxemia, DIC and PH completely improved. She was weaned from blood purification therapy on the 29th day of hospitalization. She had hemolytic anemia that might have been caused by thrombotic microangiopathy (TMA), but it resolved without plasmapheresis. On the 51st day of hospitalization, the patient was transferred to another hospital for rehabilitation.ConclusionsFES can be complicated by AKI. In this case, DIC, which was difficult to differentiate from TMA, and/or renal congestion were considered to be a cause of AKI. Chest radiographs of FES may be indistinguishable from pulmonary congestion. In our case, chest radiography showed bilateral diffuse alveolar infiltrates which was not indicative of pulmonary congestion but pulmonary involvement of FES. FES is associated with PH, which may lead to right heart failure. Therefore, the patient could have developed hypovolemic shock due to hemodialysis and rapid ultrafiltration. Clinicians should pay attention to the hemodynamics when blood purification for FES is performed.

DIAGNOSIS DAN PENGOBATAN KONSTIPASI DAN MEMAR HEMATURIA PADA VESICA URINARIA AKIBAT TRAUMA PADA KUCING

A two-year-old, spayed female, calico, domestic shorthair cat (Felis catus) was admitted to IPB University Veterinary Teaching Hospital with a history of hematuria, constipation, and inappetence after being hit by a car. Clinical examination showed pyrexia and the presence of pain when the patient was palpated in the abdomen. Laboratory results showed leukocytosis, lymphocytosis, increased glutamic-oxaloacetic transaminase, increased blood urea nitrogen, proteinuria, over-creatinine, as well as blood and struvite in the urine. The radiographic analysis reported abnormalities in os vertebrae lumbalis I and radiolucent of the colon and rectum. Sonographic findings were cholecystitis, cholelithiasis, nephritis, enteritis, and cystitis. The treatments given were intravenous infusion with normal saline, a single Melovem® injection 0.35 cc, Dulcolax® one 5 mg tablet SID for two days, Samylin®Medium Breed ½ tablet once a day, Cystaid Plus® for cats SID one tab, phytomenadione injection 3 mg/kg SID for two days, Claneksi® syrups 20 mg/kg of body weight per oral BID for five days, Renate® SID per oral for eight days. On the second day of hospitalization, the patient had not pooped, so intra-rectal flushing with physiologic saline was performed, and the patient pooed with normal consistency each day after the enema procedure. Hematuria was observed during the first two days of hospitalization, while no hematuria was observed on the third day. The patient recovered after three days of hospitalization with no hematuria or other abnormal clinical signs or complications. The veterinarian discharged the patient with home treatment with the remaining oral medications.

General anesthesia with nerve blocks for a patient with femoral fracture and essential thrombocythemia: a case report.

Essential thrombocythemia (ET) is a type of myeloproliferative neoplasm characterized by an abnormal increase in platelets. We report a female patient with a severe femoral fracture and ET who underwent the femoral intramedullary fracture fixation procedure. Her past medical history included hypertension and ET. On the second day of hospitalization, her platelet count was 922 × 109/L. In our case, general anesthesia combined with a femoral nerve block and a lateral femoral cutaneous nerve block were used when the platelet count was within normal range. After surgery, the platelet count increased to 979 × 109/L despite using anticoagulant drugs and hydroxyurea. The postoperative recovery went well after the follow-up of this patient. In this case report, we provide our experience of anesthesia management and review the progress of relevant literature to provide some reference.

Right ventricular myocarditis and rapid fibrosis induced by pazopanib.

A 56-year-old woman with metastatic chondrosarcoma visited our emergency department because of chest discomfort. Treatment with oral pazopanib, a multi-targeted tyrosine kinase inhibitor that targets angiogenesis growth factor receptors, fibroblast growth factor receptors, platelet-derived growth factor receptors, and vascular endothelial growth factor receptors, was initiated 26 days previously. Electrocardiography showed new-onset significant ST elevation in the precordial leads V1–V3 and pathologic Q-waves in leads III and aVF (Panel A). The cardiac and inflammatory biomarker levels were elevated as follows: creatine kinase (CK), 705 (reference range, 32–135 IU/L); CK-myocardial band (MB) fraction, 12.5 (reference range, 0–5 ng/mL); troponin-T, 402 (reference range, 0–14 pg/mL); NT-proBNP, 11 230 (reference range, 0–287 pg/mL); and C-reactive protein, 77.3 (reference range, 0–8 mg/L). Echocardiography showed newly developed akinesia with thinning in the septum and throughout the right ventricle with markedly reduced biventricular systolic dysfunction compared with echocardiography performed 1 month ago (Panel B and Supplementary data online, Video). Luminal narrowing or thrombosis in the coronary arteries was not observed on emergency coronary angiography (Panel C). Cardiac magnetic resonance imaging performed on the second day of hospitalization showed diffuse late gadolinium enhancement in the right ventricular wall and the right side of the septum (Panel D). The nails of both hands showed hyperpigmentation and onycholysis induced by taking pazopanib (Panel E). Despite the discontinuation of pazopanib and heart failure management, she developed fatal ventricular tachycardia and cardiogenic shock (Panel F). Imaging findings show pazopanib-induced right ventricular myocarditis with subsequent rapid wall thinning and fibrosis.

Subcapsular Hematoma of the Liver and Right Renal Hematoma Complicating Eclampsia: A Case Report

Subcapsular haematoma of the liver (SCLH) is a rare and serious complication in pre-eclampsia, occurring in a relatively stereotyped but non-specific clinical picture, which often leads to a delay in diagnosis. Its secondary rupture is one of the most serious obstetrical complications with an estimated maternal mortality of 50-75% and fetal mortality of 60-80%. We reported a case of a 37-year-old woman presented to the emergency department with postpartum eclampsia, which was revealed by generalized tonic-clonic seizures. On the second day of hospitalization, the patient developed persistent epigastric pain that was resistant to analgesic treatment. Bedside abdominal ultrasound showed a moderate amount of peritoneal effusion, and a complement CT scan revealed a subcapsular hematoma of liver with moderate hemoperitoneum and right renal hematoma. The therapeutic decision was to continue close clinical and laboratory monitoring twice daily. Improvement was noted in laboratory tests on the fourth day of hospitalization, with normalization on the twelfth day.

Respiratory Syncytial Virus Dominance in Pneumonia Cases After Removal of Pandemic Restrictions

Background: Respiratory syncytial virus is one of the most important causes of lower respiratory tract infections, with high mortality and morbidity in infants and children. It can cause airway inflammation, mucosal edema, and small airway collapse. Method: We evaluated the clinical and demographic characteristics of newborns aged 0-30 days who were hospitalized in Yüzüncü Yil University Neonatal Intensive Care Unit due to lower respiratory tract infections and whose respiratory syncytial virus test was positive between 15/December/2022 and 15/February/2023. Results: Between the specified dates, 29 patients diagnosed with lower respiratory tract infections were admitted to our neonatal unit. Of the oral/nasopharyngeal swab samples sent from all of these patients, one was positive for SARS-CoV-2, one for adenovirus, one for influenza A/B, and 18 (62%) respiratory syncytial virus. The weeks of the birth of the patients who were found to be positive for respiratory syncytial virus A/B were 36.72±1.48. The number of days they spent in the hospital was 6.72±1.6, 2(11.1%) patients required intubation, and 7(38.8%) patients required noninvasive respiratory support. One patient presented with convulsions at home, and cough and fever symptoms appeared on the second day of hospitalization. All patients recovered with oxygen support, hydration, and supportive treatment and were discharged. Conclusion: The most common cause in neonates was found to be a respiratory syncytial virus. Early diagnosis and treatment are important in patients with suspected lower tract viral infections. Unnecessary antibiotic use and the spread of the disease should be prevented by increasing access to viral tests

A rare cause of abdominal pain: Acute pancreatitis due to intragastric balloon

The intragastric balloon is one of the interventional treatments used to treat obesity. This case report presents a 28-year-old woman undergoing intragastric balloon insertion to treat obesity. Thirty-five days later, she was admitted to the emergency department with acute abdominal pain, nausea, and vomiting. During the physical examination, she had pain on deep palpation in the right lower quadrant. The laboratory showed only high serum amylase levels of 563 IU/L (range 28-100 IU/L). The abdominal ultrasound did not detect gallstones or enlarged intra or extrahepatic ducts. A computed tomography scan was performed, and intragastric balloon and distal pancreatic oedema without mass and peri-pancreatic fluid collection were detected. Intravenous hydration and anti-biotherapy were started. On the second day of hospitalization, the patient's amylase value returned to the normal range (40 IU/L). The patient who tolerated oral intake was discharged on the 3rd day of hospitalization. Diagnosis of pancreatitis is made by a history of intragastric balloon insertion, a pancreatitis-like clinical picture, and biochemical and radiological confirmation of the clinical diagnosis. In such cases, conservative therapy should be applied first; the intragastric balloon should be removed only in patients resistant to treatment or with a long-term intragastric balloon.

Abstract 15766: A Perfect [vt] Storm - How All the Wrong Factors Converged During a Dofetilide Load

Background: Dofetilide is a class III antiarrhythmic often used for the treatment of atrial fibrillation. Given its QTc prolonging properties, it is invariably initiated in an inpatient setting. While admissions for this drug are often unexciting, pharmacologic cardioversion in general and dofetilide in particular carry unique hazards. Objective: To review a case where several risk factors converged during a dofetilide load to produce a life threatening event. Case: A 75 year old male in persistent atrial fibrillation was admitted for dofetilide and started on 500 mcg PO Q12 (based on QTc and GFR). He did not experience any QTc prolongation after his first two doses, and converted to sinus rhythm on his second day of hospitalization. With this, he had an abrupt decrease in heart rate from 110 to 60 bpm. Within minutes, he suddenly developed flash pulmonary edema and required treatment for acute heart failure with IV diuresis. Fortunately, he improved with therapy in time to receive his third dose, after which QTc remained at 450. However, he had non sustained polymorphic ventricular ectopy overnight. His full AM dose was given before the monitor was reviewed (given his normal QTc), and within 2 hrs of this fourth dose, QTc prolonged markedly. He developed ventricular bigeminy with long-coupled PVCs. Subsequently, he developed sustained torsades requiring chest compressions and defibrillation. The patient recovered well, and dofetilide was discontinued. Conclusion: Acute heart failure after restoration of sinus rhythm is an uncommon but known complication of cardioversion, both electrical and pharmacologic. Furthermore, hemodynamic derangement is known to decrease arrhythmia threshold, which, along with his abrupt drop in heart rate and recent diuresis, likely contributed to the development of torsades. Furthermore, while his QTc appeared numerically acceptable before the fourth dose was given, later review revealed an abnormal T wave morphology with prolonged T peak to end time, which might have prompted a dose change if recognized. In short, monitoring dofetilide patients involves more than just GFR and QTc - other observable factors can portend poor outcome.

ODP257 Alpelisib Treatment Associated With Severe Diabetic Ketoacidosis in a Patient With Metastatic Breast Cancer

Abstract Introduction Alpelisib is an inhibitor of phosphatidylinositol-4,5-bisphosphate 3-kinase (PIK3CA) which was approved by US FDA to treat postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer. PIK3CA signaling is important for the metabolic actions of insulin and inhibition of PIK3CA was associated with hyperglycemia and rarely, ketoacidosis. Case Presentation An 82-year-old female patient with medical issues of metastatic breast cancer with recent progression started on Alpelisib one month before presentation. The patient was brought to the emergency department due to altered mental status and seizure on the same day of the presentation. She was tachycardic to 141 beats per minute and tachypneic to 22 breaths per minute. Physical exam was significant for encephalopathy and a right firm and indurated breast. Initial lab tests revealed leukocytosis to 13.1K/ uL, Blood glucose: 1124 mg/dl, Bicarbonate: 13, anion gap of 45, positive urine ketones, calculated Serum Osmolality: 386 mOsm/kg, HbA1c: 9.1, elevated corrected sodium to 147 mEq/L and elevated creatinine to 3.26 mg/dl from baseline of 0.61 mg/dl. Brain imaging including CT, MRI and MRA without acute findings. Infectious and ischemic workup were negative. She was admitted to neurocritical care as a case of new onset status epilepticus and new-onset diabetes complicated by severe Diabetic Ketoacidosis (DKA) treated with intravenous insulin drip, intravenous fluids and electrolytes replacement. During her admission, Alpelisib was held. The patient improved during the course of hospitalization with resolution of encephalopathy and ketoacidosis by the second day of hospitalization. She was transitioned from insulin infusion to multiple subcutaneous daily insulin regimen and her blood glucose readings remained controlled. Her oncologist was following and decided to stop Alpelisib and to proceed with palliative treatment until further evaluation as an outpatient. Patient was discharged home on multiple daily insulin regimen with outpatient follow ups with endocrinology and oncology. Discussion PIK3CA is the most commonly mutated gene in HR+/HER2- advanced or metastatic breast cancer and it is an indicator of poor prognosis. PIK3CA signaling is also important for the metabolic actions of insulin. Alpelisib is an inhibitor of PIK3CA. The SOLAR-1 trial, a phase 3 randomized clinical trial, showed significantly prolonged progression- free survival in patients whose tumors had a PIK3CA mutation treated with Alpelisib. However, hyperglycemia including severe ketoacidosis were also noted. Hyperglycemia was reported in 65% and ketoacidosis was reported in 0.7% of patients treated with Alpelisib. Alpelisib-induced DKA is a rare, but life-threatening, adverse event. There have been few reported cases in the literature. We want to emphasize the importance of screening, monitoring and intensifying treatment of patients with hyperglycemia who are on Alpelisib treatment. Presentation: No date and time listed

Spontaneous bleeding of an arachnoid cyst: a rare cause of thunderclap headache

Introduction A thunderclap headache is a severe headache that starts suddenly and may be a sign of a condition that can be life threatening. Objective To present a case of a rare cause of thunderclap headache. Case presentation A 37-year-old female patient was admitted in the neurological emergence service of a private hospital in the city of São Paulo. She had sudden, explosive, and pulsatile headache, with photophobia and phonophobia. The neurological examination had no focal signs. She had deep vein thrombosis in 2014 in the past and since then she has been irregularly using Warfarin. She underwent CT and MRI of the skull that showed enlargement of the bilateral retrovermian and retrocerebellar cerebrospinal fluid space, with thin membranes/septations inside, and heterogeneous content, with deposition of hemoglobin degradation products. Such findings are consistent with a retrovermian arachnoid cyst with hemorrhagic content. The INR was 1. Conservative and symptomatic treatment was started, and control CT was performed on the second day of hospitalization, demonstrating almost complete reabsorption of hematic material. The patient was discharged after 2 days of hospitalization with complete headache improvement. Conclusion Arachnoid cysts are collections of fluid located between the meningeal membranes. They are congenital and are formed due to a valve defect in the arachnoid membranes leading to a collection of cerebrospinal fluid (CSF) in its interior. Most arachnoid cysts are an incidental finding. About 1 to 2% of the population has an arachnoid cyst and symptoms appear when the cyst increases in size or bleeds. Our patient had a are complication of and arachnoid cyst not related with the use of anticoagulant. Keywords: Thunderclap headache, Arachnoid Cyst Bleeding, Arachnoid Cyst.

Cardiometabolic Risk after SARS-CoV-2 Virus Infection: A Retrospective Exploratory Analysis.

The aim of this study is to characterize the cardiometabolic risk of individuals who were infected with the SARS-CoV-2 virus and subsequently admitted to a hospital in a major city in mainland Portugal. This is a retrospective exploratory study using a sample of 102 patients, with data analysis including descriptive statistics, nonparametric measures of association between variables based on Spearman's rank-order correlation, a logistic regression model for predicting the likelihood that an individual might eventually pass away, and a multiple linear regression model to predict a likely increase in the number of days an infected patient remained in the hospital. About 62.7% of the individuals required intensive care on the second day of hospitalization, remaining 14.2 days in the intensive care unit (ICU) on average. The likelihood that an individual might eventually pass away due to SARS-CoV-2 virus infection increases for the older than younger ones and increases even more if he/she suffers from cardiometabolic disorders such as obesity, especially cardiovascular disease. Older individuals and those with obesity and hypertension remained more days in the ICU. A later age and the prevalence of cardiometabolic disorders severely affect the care pathway of individuals infected with the SARS-CoV-2 virus.

S2686 A Rare but Potentially Fatal Cause of Abdominal Pain: Segmental Arterial Mediolysis

Introduction: Segmental arterial mediolysis (SAM) is a rare disease, defined as a nonatherosclerotic, noninflammatory disruption of the arterial medial layer of a medium- to large-sized artery. We describe a case of a healthy woman with acute onset abdominal pain subsequently found to have spontaneous peritoneal hemorrhage from SAM. Case Description/Methods: A 52-year-old former professional female athlete developed abrupt onset lower abdominal pain with nausea and vomiting. Pain was 10/10 in severity with a sharp and crampy quality. She denied fevers, diarrhea, melena, bloody stool, ill contacts, recent travel, or prior episodes. Past medical history was significant for endometrial polyp, menopause, and iron deficiency. She had no prior surgeries. Family history included colon cancer in her father and ovarian cancer in her mother. Her abdomen was soft with tenderness in the lower quadrants with the remainder of the exam unremarkable. Labs including CBC, BMP, LFT, lipase, beta hCG, troponin, ESR, CRP, serum acetone, urinalysis, and lactic acid were reassuring. CT abdomen and pelvis with and without contrast demonstrated hyperenhancing hepatic lesions suggestive of hemangiomas. Ultrasound of the pelvis with duplex was normal with arterial and venous duplex waveforms to both ovaries. On the second day of hospitalization, she had another episode of abdominal pain with labs demonstrating a hemoglobin drop from 13.7 g/dL to 10.2 g/dL. Repeat CT abdomen pelvis with contrast demonstrated large volume hemorrhagic ascites up to 16 cm in size with concerns for active hemorrhage in the left upper quadrant. Diagnostic angiography was performed by Interventional radiology which did not show active arterial hemorrhage although demonstrated fusiform dilatation of the distal middle colic artery and short segment focal fusiform dilatation of the left colic artery at the splenic flexure suggestive of SAM. She subsequently underwent diagnostic laparoscopy and evacuation of hemoperitoneum with over 1L of unclotted blood evacuated with a mesenteric hematoma noted in the distal transverse and proximal descending mesocolon. The spontaneous peritoneal hemorrhage was thought to be secondary to underlying arterial abnormalities triggered by minor trauma. (Figure) Discussion: Vascular causes of abdominal pain such as segmental arterial mediolysis are uncommon. Awareness of noninflammatory and nonatherosclerotic artery diseases such as SAM need to be recognized since they can be fatal if not treated promptly.Figure 1.: Fig 1 demonstrates a bleeding artery as seen on CT abdomen and pelvis with intravenous contrast. Fig 2 demonstrates the large hemoperitoneum in the left upper quadrant seen on CT abdomen and pelvis.

Physical Activity and Fall Prevention in Geriatric Inpatients in an Acute Care Unit (AGIR Study): Protocol for a Usability Study

BackgroundFalls are one of the world’s top 10 risks associated with disability in people older than 60 years. They also represent more than two-thirds of adverse events in hospitals, mainly affecting patients older than 65 years. Physical activity is a central intervention in fall prevention for older people. Whatever the details of the prevention strategy that is adopted (ie, how a mono- or multifactorial intervention is evaluated, the category of person the intervention targets, and where it is used), it is important to ensure that the proposed intervention is feasible and usable for the patient and the health care team.ObjectiveThe primary objective is to study the usability of carrying out a physical activity intervention, including 3 types of exercises, in older patients hospitalized in a geriatric acute care unit and categorized according to 3 fall risk levels: low, moderate, and high. The secondary objectives are to determine the difficulty of the physical exercise for patients with different fall risk levels, to study the health care team’s perceptions of the intervention’s feasibility, and to study the benefits for patients.MethodsThis is an open-label, unicenter, nonrandomized, usability prospective clinical trial. The intervention tested is a daily physical activity program. It consists of 3 types of physical exercise: staying out of bed for at least 3 hours, performing balance exercises while standing for 2 minutes, and the Five Times Sit to Stand transfer exercise. These exercises are carried out under the supervision of the health care team. Fall risk in the patients is classified with the Brief Geriatric Assessment tool. The exercise program starts on the second day of hospitalization after inclusion in the study. Patient assessment continues until the last day of hospitalization or the 20th day of hospitalization, whichever is earlier. For each fall-risk group and each type of exercise, the intervention will be defined as usable if at least 80% of the participants complete 75% or more of the exercises (ie, the ratio between the number of days when the patient completes a type of exercise and the total number of hospitalization days). The perceived feasibility by the health care team is measured with 2 scales, measuring perceived difficulty and time spent with the patient. The intervention benefit is evaluated using the performance of the Five Times Sit to Stand test before and after the intervention.ResultsThe first patient was recruited on March 16, 2015. The study enrolled 266 patients, including 75 with low fall risk, 105 with moderate risk, and 85 with high risk.ConclusionsWe have not yet analyzed the results, but our observations suggest that the usability of each type of exercise for a given patient will depend on their fall risk level.Trial RegistrationClinicalTrials.gov NCT02393014; https://clinicaltrials.gov/ct2/show/NCT02393014International Registered Report Identifier (IRRID)DERR1-10.2196/32288