Stable Clinical Condition Research Articles

The value of quantitative muscle ultrasound in monitoring muscle and fascia inflammatory activity in juvenile dermatomyositis patients.

Currently, the activity of juvenile dermatomyositis (JDM) is mainly assessed based on clinical manifestations, creatine kinase (CK) level, and magnetic resonance imaging (MRI), but certain limitations arise in these approaches for children. Thus, this cross-sectional study aimed to explore the value of ultrasound in evaluating muscle inflammation via the dynamic analysis of muscle ultrasound characteristics in children with active or stable JDM. The data of a group of children who were diagnosed with JDM and admitted to the Rheumatology and Immunology Department of the Capital Pediatric Research Institute Children's Hospital between June 2022 and November 2023, and a normal control group were collected. The clinical, ultrasound, and laboratory data of the children with active and stable JDM were collected and compared with those of a normal control group. Muscle thickness (MT), fascia thickness (FT), muscle echo intensity (EI), muscle microvascular flow imaging (MVFI) distribution, and the blood flow resistance index (RI) were measured via ultrasound for the comparative analysis. A Spearman correlation analysis was conducted to assess the correlation between the ultrasound parameters in the JDM patients, and muscle scores and laboratory indicators of disease activity. Receiver operating characteristic (ROC) curves were generated for the ultrasound parameters. Five active JDM children were dynamically followed up. The data of 26 children with active JDM, 29 with stable JDM, and 31 normal control children were collected. The patients with active JDM had significantly greater EI (median 68.9 vs. 47.4, P<0.01), increased FT (median 0.25 vs. 0.15, P<0.01), and an increased MVFI distribution (P<0.01). The Spearman correlation analysis revealed a negative correlation between increased EI, FT, and MVFI distribution, and the Childhood Myositis Assessment Scale (CMAS) score (R=-0.662, -0.673, -0.667, all P<0.05). There was a statistically significant difference in EI between the stable JDM children and healthy children (median 47.4 vs. 39.0, P<0.05). During the follow-up period, two children with slow fasciitis resolution developed soft tissue calcification. EI, FT, and MVFI distribution can be used to assess the activity status of individuals with JDM, and are correlated with clinical activity indices. EI may be abnormal even in children with a stable clinical condition, which suggests that ultrasound may more accurately reflect muscle status. Children with long-term unresolved fasciitis may be at risk of developing calcification.

A rare case of posttraumatic subdural hematoma and intratumoral hemorrhage in a left frontotemporal meningioma: a conservative approach with longitudinal follow-up. Illustrative case.

Meningiomas are common primary intracranial tumors, with associated intratumoral hemorrhage being a rare but serious complication requiring prompt diagnosis for optimal outcomes. Although spontaneous bleeding in benign meningiomas is rare, it can lead to subarachnoid hemorrhage, subdural hematoma, or intratumoral/intracerebral hemorrhage, significantly increasing morbidity and mortality. Advanced imaging and recognition of radiographic hemorrhage patterns are crucial for accurate diagnosis. Treatment is case specific, as surgical intervention is preferred for symptomatic patients, while observation might be adequate for asymptomatic cases. When surgery is not feasible, stereotactic radiotherapy or chemotherapy, which is used only as salvage therapy, is considered. The authors present the case of a 78-year-old male with a history of recurrent falls. Imaging studies revealed a posttraumatic subdural hematoma and an intratumoral hemorrhage within a left frontotemporal meningioma. The patient was managed conservatively, showing significant improvement over 6 months. Notably, there was a marked reduction in both tumor size and intratumoral hemorrhage during follow-up. This case highlights the importance of adopting case-specific management strategies for hemorrhagic complications associated with meningiomas. While surgery is crucial for symptomatic meningiomas, this case demonstrates that conservative methods can be effective for a subset of symptomatic patients with stable clinical conditions and manageable intracranial bleeding. https://thejns.org/doi/10.3171/CASE24322.

Impaired right ventricular strain is associated with worse prognosis in patients with liver cirrhosis

Abstract Introduction Cirrhotic cardiomyopathy is a complication of liver cirrhosis accounting for significant morbidity and associated with reduced patient survival. It is characterized by reduced afterload, increased cardiac output, and diastolic dysfunction. However, there are limited data regarding the prognostic significance of right ventricular (RV) mechanics. Novel echocardiographic techniques such as speckle tracking echocardiography can detect subclinical myocardial dysfunction early in the course of non-ischemic myocardiopathies. Purpose To investigate the prognostic role of RV free wall strain (RVFWS) in patients with liver cirrhosis. Methods We prospectively enrolled 70 patients with liver cirrhosis in stable clinical condition. Patients with coronary artery disease, valvular heart disease, ongoing alcohol consumption or poor acoustic window were excluded from the study. Transthoracic echocardiography was performed and RVFWS was calculated from RV focused 4-chamber views using a dedicated software. Since RVFWS was as expected negative in all patients, absolute values were used for all calculations. Clinical and laboratory examination was also performed in all patients and the Model for End-Stage Liver Disease (MELD) score a widely used tool for assessing liver disease severity was calculated. All-cause mortality at 24 months was the primary endpoint and was available in all patients. Results Mean RVFWS in the cohort was 27.4±6.3% and using a lower normal limit of 20%, reduced RVFWS was detected in six patients. According to the Spearman coefficient analysis, RVFWS was correlated with MELD (rho=0.274, p=0.023) indicating increased values in patients with more advanced liver disease. According to the univariate Cox-regression proportion hazard models RVFWS as a continuous variable was not significantly correlated with worse two year survival (HR: 1.01 (0.95-1.08, p=0.658). Interestingly, among conventional echocardiographic parameters basal RV diameter (p=0.004) and right atrial end-systolic area (p=0.008) were associated with increased risk for the primary endpoint. The association of the primary endpoint with other parameters of RV systolic function was also not statistically significant. The Multivatiate Cox Regression survival analysis, which incorporated age, sex, MELD, hemoglobin, systolic blood pressure and cardiac output, showed that among echocardiographic parameters for the evaluation of the RV, only RVFWS showed a tendency to be associated with worse survival (p=0.062). When patients were stratified into tertiles according to RVFWS values, those in the first tertile (with lower absolute RVFWS values) had significantly increased hazard for the primary endpoint (HR: 5.82, 2.18-15.8, P&amp;lt;0.001) (figure 1). Conclusions RVFWS values are within normal limits in most patients with liver cirrhosis. When adjusted for the severity of the liver disease, reduced RVFWS values are associated with worse prognosis in cirrhotics.

A stepwise treatment of gastrobronchial fistula after laparoscopic sleeve gastrectomy: A case report"

Bariatric surgery has quickly emerged as one of the most effective treatments for obesity in the world and is mostly known as a safe and effective method; however, in some cases, it may lead to life-threatening complications. One of these complications is fistula, which may result in high mortality and morbidity. The treatment methods for this condition have been subject to ongoing discussion, ranging from endoscopic procedures to surgery. However, the outcome of each approach remains uncertain for both patients and surgeons. A 21-year-old man presented with pulmonary symptoms such as cough, pleuritic chest pain, and fever two months after laparoscopic sleeve gastrectomy and in further investigations, the diagnosis of gastrobronchial fistula (GBF) was confirmed. The treatment of the patient was based on endoscopic procedures and prioritizing minimally invasive methods over surgical interventions.The treatment approach that is recommended for patients with GBF is the stepwise method, in which the next step is performed according to the patient's condition. Also, the treatment was based on minimally invasive procedures like endoscopic-based methods, also it is advisable to avoid conducting invasive treatments such as surgical procedures until the patient has shown a response to either non-invasive or minimally invasive treatments. ConclusionThe key finding of this case report emphasizes that in situations of acute or unstable conditions or even if there is still hope for treatment, it's better to avoid invasive procedures. Rather, opting for non-invasive or minimally invasive treatments is favored to stabilize the patient's clinical or lab parameters, or to maintain a steady and consistent weight. Therefore, it is advisable to refrain from or delay surgical and invasive procedures during the acute stages or when a GBF is newly diagnosed, allowing the patient to attain a more stable clinical condition and use surgical approaches as a complementary choice besides minimally invasive procedures.

Complete atrioventricular canal in a dog—sounds like a final judgment but is it actually one? A case report

Congenital heart disease (CHD) is an important subset of all cardiovascular diseases in dogs. Among them, there are a number of other less commonly described congenital malformations. One of these is the atrioventricular canal, which involves a defect that has several phenotypes. This report details a case of a complete atrioventricular canal (cAVC) defect. Using Rastelli’s classification scheme, the diagnosis of a type-A cAVC defect was based on two-dimensional, contrast, and color Doppler echocardiography. Despite a severe defect that resulted in the atypical anatomy of the atrioventricular apparatus, as well as significant hemodynamic changes in the heart, the affected dog remained asymptomatic throughout the 48-month follow-up period. Due to its stable clinical condition, the decision was made not to begin pharmacological therapy. As this defect is rare in dogs, there are limited data in the literature on this condition. Therefore, in clinical practice, the management and monitoring of the patient may pose difficulties. Due to such limited data, it can be very difficult to provide a prognosis. For the above reasons, we hope that the following case will contribute valuable information for the monitoring of this kind of CHD.

Ізольована гіпоплазія правого шлуночка: діагностика, лікування та досвід спостереження пацієнтів дитячого віку

Isolated hypoplasia of the right ventricle (IHRV) is a rare congenital heart defect characterized by a reduction of the right ventricular cavity due to hypoplasia of its trabecular part. Aim - to analyze the anatomical variants of IHRV and their influence on the choice of treatment tactics based on the experience of observing pediatric patients. Materials and methods. This retrospective study included 11 consecutive patients diagnosed with IHRV from 2012 to 2024. Patients were divided into 3 groups based on the ratio of RV to left ventricle (LV) length. The Group I (n=4): mild IHRV (RV/LV length ratio &gt;0.8). The Group II (n=4): moderate IHRV (RV/LV length ratio = 0.7-0.8). The Group III (n=3): severe IHRV (RV/LV ventricle length ratio &lt;0.67). Results. From the Group I (n=4), one patient required medication therapy with beta-blockers and others did not require any treatment. From the Group II (n=4), one patient underwent Glenn shunt and patent foramen ovale (PFO) closure, another - Glenn shunt and PFO closure with fenestration. Two patients have stable clinical conditions. Patients from the Group III (n=3) had duct-dependent pulmonary blood flow in the neonatal period. One patient received treatment with beta-blockers; the second patient underwent patent ductus arteriosus stenting; and the third - systemic-to-pulmonary shunt. Conclusions. Patients with severe IHRV may have critical hemodynamic disturbances requiring urgent cardiac surgical interventions, whereas patients with mild and moderate hypoplasia may require medical treatment with possible surgical intervention at a later age. Long-term follow-up in this defect reveals a slow progressive growth of the right heart chambers. The research was carried out in accordance with the principles of the Declaration of Helsinki. Informed consent of the child and child's parents was obtained for the research. The authors declare no conflict of interest.

IMG-26. USING [18F]FET-PET/CT SCAN TO DIFFERENTIATE RADIONECROSIS FROM RECURRENCE/NEW TUMOURS: THE CASE OF A CNS SARCOMA

Abstract CASE REPORT A 5-year-old girl diagnosed with a posterior fossa standard-risk medulloblastoma underwent surgery followed by proton therapy (PT) 23.4 Gy(RBE) (1.8 Gy(RBE)/fr) to the craniospinal axis plus a boost of 30.6 Gy(RBE) (1.8 Gy(RBE)/fr) to the tumor bed and maintenance chemotherapy according to HIT-SIOP PNET 4 protocol. The patient remained disease-free for 4 years after the end of treatmen. MRI showed a new left temporo-occipital lesion 8x10x10 mm which was irradiated from cranial field during the craniospinal phase but outside of the boost area, consistent with inoperable recurrence. She was then re-irradiated with a second course of PT 50.4 Gy(RBE) (1.8 Gy(RBE)/fr) and subsequently started on temozolomide. Periodic MRI scans showed progressive reduction of the lesion for 10 months, when new lesion progression occurred within the re-irradiated fieled. Considering the stable clinical conditions of the patient, the minimal size of the lesion, and the uncertain nature between actinic damage or cancer, a watchful waiting approach was adopted. Few months later, the area increased. [18F]FET-PET/CT evaluation documented an uptake of the drug compatible with metabolically active lesion. A biopsy was performed, and histology showed a CNS sarcoma. Genetical testing excluded cancer predisposition syndromes. Chemotherapy with bevacizumab and irinotecan was started, but the MRI showed significant progression of the disease and the patient died 6 months after the diagnosis. CONCLUSION MRI is the main diagnostic method in the follow up of CNS neoplasms, but it has limitations in discriminating recurrences/secondary tumours and tissue changes due to previous treatments, particularly radiotherapy. Recently, the use of [18F]FET-PET/CT is being investigated, but literature is still poor in children and most cases refer to high-grade gliomas. It is desirable to study it further, as it may play a relevant role in differentiating equivocal cases, as in our patient.

P.073 Spontaneous fluctuation of contrast enhancement in adult pilocytic astrocytoma and other low-grade brain tumors

Background: Pilocytic astrocytoma and other circumscribed low-grade brain tumors can exhibit spontaneous enhancement changes despite stable size and clinical status. We aimed to describe this phenomenon in adults. Methods: We performed a retrospective review of our MRI database (2011-2021) to identify cases with enhancement changes in otherwise stable tumors. We searched for reports containing: “pilocytic”, “pilomyxoid”, “RGNT”, “rosette”, “glioneuronal”, “DNET”, and “dysembryoplastic”. Exclusion criteria included WHO grade 3/4 tumors, patients &lt;19 years, equivocal diagnostic findings, and no serial MRIs. We reviewed 238 patients. Results: We identified 12 adult patients with the desired phenomenon: 6 pilocytic astrocytoma, 1 pilomyxoid astrocytoma, 2 rosette-forming glioneuronal tumor, 1 unverified low-grade glioma, and 2 cases without biopsy. Seven were untreated, while five were residual or recurrent tumors. Six showed a pattern of new/increasing and subsequent decreasing/disappearing enhancement over 1-4 years. One exhibited spontaneous regression of enhancement over 1 year. Five showed repeating cycles of increasing and decreasing enhancement over longer monitoring periods of 7-15 years, with mean duration of increasing enhancement prior to decline of 21.4 months (SD 5.9). Conclusions: Spontaneous contrast enhancement fluctuation in adult pilocytic astrocytoma and other circumscribed low-grade brain tumors can occur, and on its own should not be misconstrued as evidence of tumor progression/regression.

PERCUTANEOUS TREATMENT OF ABDOMINAL AORTIC ANEURYSM AND AORTIC VALVE STENOSIS WITH ‘STAGED’ EVAR &amp; TAVR

Abstract Symptomatic AS and AAA are critical clinical conditions, increasingly more prevalent with aging of the population. TAVR is a treatment of choice in high risk and inoperable patients with symptomatic severe AS, who are often elderly. A continuous increase in the number of TAVR procedures–per–year is expected due to the increasingly robust evidence that TAVR is advantageous in the population with non–increased surgical risk. Our ‘tailored’ interventional approach has planned an endovascular correction of the AAA as the first step, followed by a ‘staged’ TAVR. The AAA was treated first because was it considered strategically better in the presence of severe AS in stable clinical conditions. Moreover the potential elevation of the systolic arterial pressure after TAVR might provoke enhanced strain at the AAA wall increasing the risk of rupture. During the EVAR procedure all the material needed to proceed to an ‘urgent’ aortic valvuloplasty or TAVR if necessary was available and ready. The proposed treatment was effective in all treated patients, offering the resolution of both problems through totally percutaneous treatment in patients with a significant high risk for both mortality and vascular complications. The risk of acute kidney injury is reduced compared to simultaneous procedures because the total amount of contrast agents used overall is spread among two different procedures after an adequate time of recovery. The main clinical, technical and procedural considerations of TAVR procedure in this case series were: Transfemoral access into the bifurcated endoprosthesis was feasible in 100% of patients The use of highly supportive stiffer guides (or buddy wire technique) to overcome the tortuosity of the iliac–femoral approaches should be considered; The introducer advancement under fluoroscopic guidance and through–and–through wire technique is strongly recommended in the presence of tortuosity; The strategy to protect the main vascular access must be personalized choosing between the ipsilateral femoral approach or the radial (or omeral) approach; The total amount of contrast medium administered to patients should be carefully monitored; The procedures should always be conducted with as much ‘contrast zero‘ methods as possible. Define a delay time between EVAR and TAVR according to the clinical status, the age and the co–morbidities of patients even in the presence of clinical stability, is highly debated.

Spontaneous idiopathic liver hemorrhage: a systematic review of a rare entity.

Spontaneous idiopathic liver hemorrhage (SILH) is a rare life-threatening condition occurring without a clear and specific etiology. A systematic review was performed to provide guidelines for the perioperative management of patients affected by SILH. A case report was also included. A systematic search of the last 24-year literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. After an initial selection of 6995 titles, 15 articles were considered for the final qualitative analysis (n = 22 patients, including the present report). Conservative treatment was chosen in 12 cases (54.5%) with stable clinical conditions, while 9 patients (40.9%) required a primary operative approach for emergency presentation at diagnosis. Direct liver resection was the preferred surgical treatment (n = 6), mostly major hepatectomies (n = 4). Hepatic arterial embolization was performed as the primary operative approach in three patients, followed by emergency laparotomy during the same hospitalization because of rebleeding in one case. Contrast-enhanced CT scan was the gold standard for diagnosis (n = 19). Conservative treatment of SILH is mainly based on stable clinical conditions and may be considered even in case of a limited arterial blush found on imaging. The absence of underlying hepatic or systemic disorders seems to correlate with favorable outcomes and no mortality.

Long-term oxygen therapy to reduce length of hospital stay in COVID-19.

The aim of this study was to evaluate the efficacy of long-term oxygen therapy as a strategy to reduce hospitalization time in patients affected by COVID-19. Between April and December 2021, COVID-19 patients with stable clinical conditions needing supplementary oxygen therapy during hospitalization were oriented to have hospital discharge with long-term oxygen therapy and reassessment after 15 days. A total of 62 patients were evaluated and, 15 days after discharge, 69% of patients had suspended long-term oxygen therapy, with no difference between the groups admitted to the intensive care unit or the ward (p=0.319). Among the individuals who needed to maintain long-term oxygen therapy, in addition to worse P/F ratio (265±57 vs. 345±51; p<0.001) and lower partial pressure of oxygen (55±12 vs. 72±11 mmHg; p<0.001), were those more obese (37±8 vs. 30±6 kg/m2; p=0.032), needed more time for invasive mechanical ventilation (46±27 vs. 20±16 days; p=0.029), had greater persistence of symptoms (p<0.001), and shorter time between the onset of symptoms and the need for hospitalization (7 [2-9] vs. 10 [6-12] days; p=0.039). Long-term oxygen therapy is an effective strategy for reducing hospitalization time in COVID-19 patients, regardless of gravity. Additionally, more obese patients with persistence of respiratory symptoms, faster disease evolution, and more days of invasive mechanical ventilation needed to maintain the long-term oxygen therapy longer.

Conservative Management of Ectopic Pregnancy Following Depot Medroxyprogesterone Acetate Injection: A Case Report

Objectives: Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The use of progesterone-containing contraceptives is a risk factor for ectopic pregnancy. This study reports a rare case of ectopic pregnancy following a depot medroxyprogesterone acetate (DMPA) injection that was managed conservatively. Case Presentation: A 36-year-old woman (gravida 2) was referred to the Gynecology Clinic of the Persian Gulf Hospital, Bandar Abbas, Iran with a history of amenorrhea, vague pelvic pain, and no past medical history, except for DMPA injection, three months before the symptoms. Ectopic pregnancy was determined based on ultrasonography and beta-human chorionic gonadotropin (BHCG) evaluation. The patient was managed conservatively with serial ultrasonography and BHCG titration due to normal laboratory tests, stable clinical status, and a decline in BHCG titration. Conclusion: Amenorrhea and pelvic pain in all women of childbearing age should be considered an alarming sign of ectopic pregnancy. In case of stable hemodynamic status, the patient can be conservatively managed with serial trans-vaginal ultrasonography and evaluation of serum BHCG till the resolution of symptoms.

Arterial hypertension, chronic kidney and severe valvular heart disease predict worse outcome after postponing non-emergency cardiac interventions during the COVID-19-pandemic

Abstract Background Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalizations. Criteria to identify patients at risk for adverse events when postponing their scheduled intervention are needed. Aim The aim of this study was to identify predictors associated with worse clinical outcome in cardiac patients whose non-emergency cardiovascular intervention has been deferred during the COVID-19 pandemic. Methods This monocentric retrospective study included patients whose non-emergency cardiac intervention has been postponed during COVID-19-related lockdown between March 19th and April 30th 2020. Cox regression was performed to identify predictors of the combined endpoint emergency cardiovascular hospitalization and death. Patients’ outcome after 12 months was compared to a seasonal control group undergoing non-emergency interventions in 2019 as scheduled. Results The combined endpoint of death and emergency cardiovascular hospitalization occurred in 70 (36.5%) of 193 patients with a postponed cardiovascular intervention. The planned intervention was deferred by a median of 23 [19 – 36] days. Arterial hypertension (Hazard ratio [HR] 2.27; 95%-Confidence interval [CI] 1.00-5.12; P=0.049), chronic kidney disease (HR 1.89; 95%-CI 1.03 – 3.49, P=0.041) as well as severe valvular heart disease (HR 3.08; 95%-CI 1.68-5.64; P&amp;lt;0.001) were independent predictors of death or emergency hospitalization. Kaplan-Maier estimators of the combined endpoint were 31% in patients with arterial hypertension, 56% in patients with severe valvular heart disease and 77% with both risk factors (HR 12.4, 95%-CI 3.8-40.7; P&amp;lt;0.001) and only 9% in patients without these risk factors (log rank P&amp;lt;0.001). Separate analyses of patients with arterial hypertension, chronic kidney disease and severe valvular heart disease revealed that deferred patients showed significantly poorer clinical outcomes when compared to the control group 2019 (log rank P&amp;lt;0.001, P=0.006 and P&amp;lt;0.001, respectively). NT-proBNP cut-off ≥ 1,109 pg/ml best predicts the occurrence of primary endpoint event in deferred patients (AUC 0.71; P&amp;lt;0.001; sensitivity 64%, specificity 69%). Conclusion Our results suggest that patients with either arterial hypertension, chronic kidney or severe valvular heart disease are at very high risk for emergency hospitalization and increased mortality in case of postponed cardiac interventions even in supposed stable clinical status. Risk is even higher in patients suffering from a combination of these conditions. In addition, measuring NT-proBNP levels might help to identify those at high or very high risk.

INDIVIDUAL CORRELATION OF OXYGEN DELIVERY WITH HAEMOGLOBIN LEVEL IN 20-YEAR-OLD WOMAN WITH HB 1.8 WITH INCOMPATIBLE CROSS-MATCH RESULTS: CASE REPORT STUDY

BACKGROUND&#x0D; Clinical assessment of the delivery of tissue oxygenation is very challenging for clinicians to study. Anaemia reflects a decrease in oxygen carrying capacity in the blood which is very at risk of oxygen delivery (DO2) insufficiency and cellular hypoxemia, to assess tissue hypoxia in addition to being a reliable tool, the clinician must also adjust to the patient's clinical and hemodynamic. Blood transfusions are generally used to correct anaemia precisely and efficiently, but in certain circumstances that make it impossible for clinicians to perform blood transfusions, at that time we have to think of other methods of therapy in patients.&#x0D; METHODS&#x0D; 20-year-old woman came with anaemia, with a haemoglobin (Hb) level of 6.0 g/dl, a stable clinical condition and hemodynamic within normal limits, a blood transfusion was planned but the results of the Comb test was incompatible, so it was an absolute contraindication for transfusion. The patient experienced clinical changes that indicated the occurrence of tissue hypoxia when the Hb level was 2.0gr/dl. The clinician decided to maximize DO2, and reduce oxygen demand/consumption (VO2), so that there is a balance. The patient was treated with steroids, suspected autoimmune haemolytic anaemia (AIHA). On the eighth day of clinical treatment the patient improved, hemodynamically stable, and Hb increased.&#x0D; CONCLUSION&#x0D; Clinical valuation of the distribution of tissue oxygenation is very important for AIHA patient.

Mild traumatic brain injury: not always a mild injury.

In general, risk of mortality after trauma correlates with injury severity. Despite arriving in relatively stable clinical condition, however, some patients are at risk of death following mild traumatic brain injury (TBI). The study objective was delineation of patients who die in-hospital following mild isolated TBI in order to inform Emergency Department (ED) disposition and care discussions with patients and families. In this retrospective cohort study, patients from the National Trauma Data Bank (NTDB) (2007-2018) were included if they were injured by blunt trauma and sustained a mild TBI (defined as Head Abbreviated Injury Scale [AIS] score of 1 or 2 and arrival Glasgow Coma Scale [GCS] score of 13-15). Exclusions were severe associated injuries (extracranial AIS > 2); transfers; and missing data. Patients were defined by in-hospital mortality: Survivors vs. Mortalities. Demographics, clinical/injury data, and the outcomes were collected and compared with univariate analysis. Multivariate analysis established independent factors associated with in-hospital mortality following mild TBI. In total, 932,107 patients (10% of NTDB population) met study criteria: 928,542 (99.6%) Survivors and 3,565 (0.4%) Mortalities. In general, comorbidities (including home anticoagulation, cardiac disease, and diabetes mellitus) were significantly more common among patients who died (p < 0.001), although drug and alcohol intoxication on arrival were more common among Survivors (16% vs. 7%, p < 0.001; 13% vs. 10%, p < 0.001). In terms of insurance status, Private/Commercial insurance was more common among Survivors (39% vs. 20%, p < 0.001) while Governmental Insurance was more common among Mortalities (55% vs. 36%, p < 0.001). On multivariate analysis, age ≥ 65 was most strongly associated with death (OR 26.43, p < 0.001), followed by ED intubation (OR 10.08, p < 0.001), admission hypotension (OR 4.55, p < 0.001), and comorbidities, particularly end-stage renal disease (ESRD) (OR 3.03, p < 0.001) and immunosuppression (OR 2.18, p < 0.001). Survivors differed substantially from Mortalities after mild TBI in terms of comorbidities, intoxicants, and insurance status. Independent variables most strongly associated with in-hospital death following mild head injury included age ≥ 65, intubation in the ED, admission hypotension, and comorbidities (particularly ESRD and immunosuppression). Increased clinical vigilance, including a mandatory period of clinical observation, for patients with these risk factors should be considered to optimize outcomes and potentially mitigate death after mild TBI.

Chylothorax after chimeric antigen receptor T cell therapy for relapsed and refractory diffuse large B-cell lymphoma: A case report.

Anti-CD19-targeted chimeric antigen receptor (CAR) T cell therapy is effective in treating relapsed/refractory diffuse large B-cell lymphoma (DLBCL). This therapy is associated with several side effects that can be life-threatening such as cytokine release syndrome (CRS). However, chylothorax associated with CRS after CAR-T therapy has not been reported. A 23-year-old male diagnosed with DLBCL relapsing after autologous peripheral blood stem cell transplantation was treated with anti-CD19-targeted CAR-T cell therapy. After CAR-T cell transfusion, he developed grade 3 CRS includes fever, dyspnea, tachycardia and hypotension. The symptoms of CRS persisted and chest plain film revealed bilateral pleural effusion. Chylothorax was confirmed by the pleural effusion analysis that triglyceride level was 1061 mg/dL. Bacterial and fungal culture of pleural fluid reported no pathogen was detected. Cytological examination of pleural effusion revealed no malignant cells. The chylothorax resolved after treatment with intravenous administration of tocilizumab. On 30-day follow-up, the patient was in stable clinical condition with complete remission of DLBCL on whole-body positron emission tomography scan. We reported a rare case of CAR-T associated chylothorax in a patient with relapsed and refractory DLBCL. Grade 3 CRS with high interleukin-6 level was presented in our patient. The symptoms of CRS were improved with tocilizumab treatment and the chylothorax resolved later on. It is suggested that high interleukin-6 releases might induce chyle leakage resulting from activations of endothelium and coagulation. Our finding highlights the occurrence of chylothorax during the course of CAR-T cell therapy and the importance of proper monitoring and prompt management of this life-threatening side effect.

Partial Molar Pregnancy within the Fallopian Tube: A Rare and Challenging Entity

There have been a small number of ectopic molar pregnancies reported with estimates being around 1.5 in every 1,000,000 pregnancies. Ectopic pregnancy and molar pregnancy are not rare events with their incidence being 20 in every 1000 and 1 in every 500 to 1000 pregnancies respectively but their combination that is ectopic molar pregnancy is a rare entity so often not considered as a diagnostic possibility. Among ectopic pregnancies, fallopian tubes are the most common site (98% cases). Only 0.7 % of GTD (Gestational trophoblastic diseases) occur in Fallopian tube. Hydatidiform mole is the most common and a pre malignant form of GTD that occurs due to derranged fetal and placental development. Hydatidiform mole, a type of Gestational Trophoblastic disease, is an abnormal form of pregnancy/gestation which results from abnormal fertilization. Hydatidiform mole can either be a partial mole or complete mole. We report a case of a 30-year-old female with ruptured ectopic pregnancy, who initially presented with stable clinical status.

Pulmonary hypertension rapidly leading to mortality in a patient with interstitial pneumonia with autoimmune features

Interstitial Pneumonia with Autoimmune Features (IPAF) is a newly defined connective tissue disease (CTD) related pulmonary involvement in 2015 by the European Respiratory Society and American Thoracic Society. It is used to define the subgroup of patients with no known CTD history. In this case report, we present a patient with IPAF diagnosis, who had rapid clinical deterioration after a COVID-19 infection, which was attributed to a newly diagnosed pulmonary hypertension. A 69-year-old male patient with chronic obstructive pulmonary disease (COPD) diagnosis was on the routine follow-up for a duration of five years. He had been diagnosed with type 2 diabetes mellitus and gout, with under constant follow-up for a known cardiovascular arterial disease history. During a routine pulmonary evaluation, the patient had stated a worsening exercise capacity and an increase in coughing. The requested high-resolution computed tomography showed emphysema at the upper lobes and a reticular pattern at the lower lobes, with honeycombing, traction bronchiectasis, and ground-glass findings. After a rheumatology consultation, which excluded the presence of an underlying rheumatological disease, the patient was diagnosed with IPAF. Under immunosuppressive treatment, the patient complained of increased dyspnea at a routine follow-up after a COVID infection in 2021, and antifibrotic treatment was initiated due to the progression of pulmonary fibrosis. During routine follow-up, further limitation in exercise capacity was evident, for which extra-pulmonary involvement was investigated. Pulmonary hypertension (PH) diagnosis was confirmed with vasoreactivity positivity; however, due to both progression in IPAF and concurrent PH, the patient was lost during the follow-up. As seen in this case, despite being stable for years, the addition of another comorbidity may rapidly worsen a patient’s otherwise stable clinical condition. While antifibrotic regimens may be used on a case-by-case basis, their effect on disease progression may not be sufficient to control an already present comorbidity, such as pulmonary hypertension.

P302 SIMULTANEOUS CORRECTION OF SEVERE LOW–FLOW LOW–GRADIENT AORTIC STENOSIS AND ABDOMINAL AORTIC ANEURYSM BY TAVI + EVAR

Abstract We report the case of a 72–year–old man with arterial hypertension, dyslipidemia, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease. The patient had a previous stroke with occlusion of both internal carotid arteries about 7 years ago. He presented to the emergency department with dyspnea on exertion (NYHA class III), and the echocardiogram revealed a dilated left ventricle with severe reduction of global systolic function (EF 35%), severe low–flow low–gradient aortic stenosis (AVA on VTI 0.526 cmq/mq, SVi 29.7 ml/mq, Gmax 25.6 mmHg, Gmed 16 mmHg), and abdominal aortic aneurysm. Subsequently, he underwent an angio–CT scan that showed an almost completely thrombosed abdominal aortic aneurysm with a maximum diameter of 65 mm and a longitudinal extension of about 11 cm. The patient also underwent coronary angiography, which showed diffuse calcified atherosclerosis, and he was recommended for medical therapy. After a joint Heart Team consultation with cardio–anesthesiologists, cardiac surgeons, and vascular surgeons, it was decided to perform transfemoral transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (EVAR) in the same procedure (EUROSCORE II &amp;gt; 4%). The patient underwent TAVI followed by EVAR of the aorto–bisiliac arteries through a main access site in the left femoral artery guided by ultrasound, a secondary access site in the right femoral artery for placement of a pigtail catheter on the aortic plane, and a venous access site in the right femoral vein for placement of a temporary pacing catheter at the apex of the right ventricle. First, an Edwards Sapien 3 Ultra 26mm valve was implanted, and then the 14Fr sheath in the left femoral artery was exchanged for an 18Fr sheath for the EVAR, which was placed in the aorto–bisiliac region. Hemostasis was achieved using the Manta system on the left femoral artery and two Proglide devices on the right femoral artery. The procedure was completed without complications, and the patient was discharged 10 days later, asymptomatic and in stable clinical condition, with a recommendation for dual antiplatelet therapy with aspirin and clopidogrel. At the 6–week follow–up, the patient remained asymptomatic with an EF of 40%. Conclusion In selected cases, the simultaneous correction of severe low–flow low–gradient aortic stenosis using TAVI and abdominal aortic aneurysm using EVAR can be considered after appropriate discussion and consultation within the Heart Team."

P479 PATIENT WITH REGRESSION MULTIPLE MYELOMA AND INFILTRATIVE HYPERTROPHIC CARDIOMYOPATHY OF NDD UNDERGO CARDIAC TRANSPLANT

Abstract Introduction We report the case of a 52–year–old patient with a history of multiple myeloma undergoing chemotherapy treatment according to the DaraRD scheme and currently in remission. Associated with haematological pathology, infiltrative hypertrophic cardiomyopathy of ndd is highlighted. Following haematological and instrumental screening tests, the patient underwent a heart transplant for frequent exacerbations of heart failure. Case Report A 52–year–old patient, suffering from multiple myeloma for about 1 year, for which he began chemotherapy treatment with DaraRD scheme and good response to therapy. The patient also presented dyspnoic symptoms and declining edema with echocardiographic finding of infiltrative hypertrophic heart disease for which he undergoes diagnostic investigations. He performs: • Serial echocardiograms which showed marked uniform hypertrophy with ground glass appearance of the left ventricle and severely reduced systolic function; • PET–CT with no hyperaccumulation of the radiopharmaceutical; • Cardiac MRI with evidence of severely hypocontractile left ventricle and wall changes which could be associated with amyloid infiltration; • myocardial scintigraphy that does not give evidence for the deposit of the amyloid substance of the ATTR type in the heart; • biopsy of umbilical fat and cardiac biopsy, both negative for deposition of substance AL with Congo Red staining; • Right cardiac catheterization with evidence of post–capillary pulmonary hypertension. The patient was subjected to several exacerbations of heart failure which required continuous infusion therapy with inotropes and, ultimately, heart transplantation. At the time of surgery, the heart appeared enlarged, extremely hypocontractile and with rigid walls, with poor compliance of the ventricular muscle wall. The patient responded well to the surgical procedure, in the absence of signs and symptoms of rejection, with improvement of general clinical condition. Conclusions At the end of the surgical procedure and the rehabilitation period, the patient was discharged home, without showing signs and symptoms of graft rejection or multiple myeloma exacerbations, in stable and satisfactory general clinical conditions.