Strong Suspicion Research Articles

Investigating the Impact on Long-Term Outcomes and the Necessity of Hereditary Thrombophilia Screening in Presumed or Perinatal Arterial Ischemic Stroke.

This study aimed to investigate the influence of prothrombotic risk factors on long-term outcomes of patients with perinatal arterial ischemic stroke. The study was conducted through an analysis of monitoring results that were regularly maintained for approximately 20 years at a tertiary stroke-monitoring center. The study assessed prothrombotic risk factors, radiological area of involvement, clinical presentation, treatments, clinical outcomes, and long-term outcomes of the 48 patients included in the study, with a mean monitoring time of 77.6 ± 45.7 months (range: 6-204). Our results showed that the presence of prothrombotic risk factors did not affect long-term outcomes. However, patients with middle cerebral artery infarction had the highest risk of developing cerebral palsy, whereas those with presumed stroke had the highest risk of developing epilepsy. This study suggests that prothrombotic risk factors should not be evaluated during the acute stage unless there is a strong suspicion of the patient's history, and prevention or early diagnosis of presumed stroke patients will positively impact their long-term prognosis.

Enhancing thalassemia gene carrier identification in non-anemic populations using artificial intelligence erythrocyte morphology analysis and machine learning.

Non-anemic thalassemia trait (TT) accounted for a high proportion of TT cases in South China. To use artificial intelligence (AI) analysis of erythrocyte morphology and machine learning (ML) to identify TT gene carriers in a non-anemic population. Digital morphological data from 76 TT gene carriers and 97 controls were collected. The AI technology-based Mindray MC-100i was used to quantitatively analyze the percentage of abnormal erythrocytes. Further, ML was used to construct a prediction model. Non-anemic TT carriers accounted for over 60% of the TT cases. Random Forest was selected as the prediction model and named TT@Normal. The TT@Normal algorithm showed outstanding performance in the training, validation, and external validation sets and could efficiently identify TT carriers in the non-anemic population. The top three weights in the TT@Normal model were the target cells, microcytes, and teardrop cells. Elevated percentages of abnormal erythrocytes should raise a strong suspicion of being a TT gene carrier. TT@Normal could be promoted and used as a visualization and sharing tool. It is accessible through a URL link and can be used by medical staff online to predict the possibility of TT gene carriage in a non-anemic population. The ML-based model TT@Normal could efficiently identify TT carriers in non-anemic people. Elevated percentages of target cells, microcytes, and teardrop cells should raise a strong suspicion of being a TT gene carrier.

Ear, nose and throat foreign bodies in the pediatric age. An experience in a quaternary care hospital in Maputo, Mozambique

Foreign bodies are very common in emergency services. The aim of this study is to analyze FBs in pediatric age, in terms of type, location, age, and gender and method of extraction, type of anesthesia and complication. The present study is a retrospective cross-sectional study based on records from the Mozambican hospital (1983-2009). These were specifically based on medical records for all pediatrics patients diagnosed with the presence of a FB in Otolaryngology. During the study period, 3130 patients under 14 years of age visited this hospital with FB in the ear, nose and throat area; 54.34% were males. Of the 3130 patients, 40.47% had FB in the ear, 32.74% in the esophagus, 18.62% in the nose. The FB was removed with anesthesia in 59.7% patients. In adults the FB story is clear, but in young children it is a challenge, because they do not tell for fear of being heard, or out of shame and a strong suspicion is crucial to avoid unwanted outcomes. The present study showed that FB are more frequent in young male children under 4 years of age, especially in the ear. General anesthesia was most often used to remove foreign bodies.

Diagnostic Accuracy of Cd1a Immuno Histochemical Evaluation in Comparison with H & E and Giemsa for Cutaneous Leishmaniasis

Background: Cutaneous leishmaniasis remains a global health challenge, with diagnosis largely dependent on the visualization of Leishmania parasites in infected tissue. Traditional staining methods, such as Hematoxylin and Eosin (H&E) and Giemsa, have been the cornerstone of histopathological diagnosis, but they come with limitations in sensitivity and specificity. Objective: This study aimed to evaluate the diagnostic accuracy of CD1a immunohistochemical staining in the detection of leishmania amastigotes in skin biopsies and compare its efficacy with H&E and Giemsa staining methods. Methods: A total of 110 skin biopsy samples with a strong clinical suspicion of cutaneous leishmaniasis were examined using H&E, Giemsa, and CD1a immunohistochemical staining techniques. The sensitivity and specificity of these methods were analyzed and compared to ascertain the most effective diagnostic approach. Results: The study identified leishmania amastigotes in 78% of the cases using H&E staining, while Giemsa staining resulted in amastigote detection in 82% of cases. Notably, CD1a immunohistochemical staining showed a remarkable sensitivity, identifying amastigotes in 95% of the samples. The increase in detection rate with CD1a staining was statistically significant when compared to H&E (p<0.05), with CD1a revealing amastigotes in an additional 23% of cases where H&E staining was negative. Giemsa staining was able to detect amastigotes in three cases that were not visible with H&E, suggesting its potential role as a complementary technique in certain diagnostic scenarios. Conclusion: The study concludes that CD1a immunohistochemical staining significantly enhances the detection of leishmania amastigotes and should be considered as an adjunct to conventional staining methods in the histopathological diagnosis of cutaneous leishmaniasis. Future diagnostic protocols could benefit from the incorporation of CD1a staining to improve accuracy.

Molecular Analysis of Liquid Vitreous Biopsy Reveals Occult Lymphoma Following Cytology-Negative Biopsies of the Brain and Vitreous

ABSTRACT Purpose Primary central nervous system lymphoma (PCNSL) is a rare but deadly malignancy that principally affects adults in the fifth and sixth decades of life. Despite diagnostic advances in analyses of cerebral spinal fluid and neuroimaging, definitive diagnosis of PCNSL requires primary brain tissue biopsy. While small neurosurgical biopsy volumes are pursued to minimize removal of normal brain tissue, the spatial margins to precisely biopsy pathologic tissue are narrow and can result in missed diagnoses. Furthermore, prior steroid treatment can significantly reduce tumor burden increasing the likelihood of a non-diagnostic biopsy. Methods A retrospective case report from a tertiary referral center using a combination of neuroradiological studies, sterotactic tissue biopsy, and molecular testing for genome mutations. Results A 72-year-old woman with strong suspicion for PCNSL clinically and radiologically, but cerebral spinal fluid and primary brain tissue biopsy were negative for tumor. However, vitreous liquid biopsy molecular testing for a MYD88 mutation as well as B-cell clonality (IGH/IGK rearrangement) were positive, indicating the presence of secondary vitreoretinal lymphoma from PCNSL. Only after autopsy of her brain was histopathological and immunohistochemical evidence of PCNSL confirmed. Conclusion This case illustrates the unique contribution of liquid biopsy neuropathology-oriented molecular testing in a challenging case with high clinical suspicion of PCNSL in which gold-standard diagnostic testing failed to yield a diagnosis.

Escherichia Coli Endocarditis and Cardiac Abscess: A Rare Presentation in a Patient with a Prosthetic Aortic Valve.

There are very few documented cases of Escherichia coli endocarditis with cardiac abscesses in the literature. Here we describe a case presentation with diagnostic challenges and a multidisciplinary approach to management. This is a rare presentation of E. coli endocarditis in a patient with a prosthetic aortic valve. Initial tests were inconclusive and further investigation with transoesophageal echocardiography was required to make the diagnosis. Despite initial improvement, the patient deteriorated and ultimately died of complications related to the presentation. E. coli is a rare causative organism for endocarditis, which can itself be difficult to diagnose. A multidisciplinary approach to investigation and treatment is required when infective endocarditis is suspected. Transoesophageal echocardiography may be required to diagnose endocarditis when there is a strong clinical suspicion and risk factors present. Infective endocarditis should be thoroughly investigated for in cases where there is a high clinical suspicion, but atypical organisms grown in blood cultures.A transoesophageal echocardiogram (TOE) may be a better imaging modality when endocarditis is strongly suspected, in comparison to a transthoracic echocardiogram (TTE).Escherichia coli endocarditis carries a high mortality rate, and early intervention is key in managing patients presenting with suspected endocarditis.

Finding the Missing Calcifications: How Deep to Cut?

Abstract Introduction/Objective Mammographic documentation of microcalcifications requires biopsy of the microcalcifications with histologic study to demonstrate that the area of mammographic interest is examined histologically to exclude carcinoma. Initial levels may not demonstrate these microcalcifications requiring study of additional levels. Little data exists as to how deeply levels should be cut to document microcalcifications. Methods/Case Report A search of pathology records at the University of Missouri between January 1, 2022 and March 30, 2023 for reports containing the term “microcalcifications” in the clinical history or specimen designation was performed. For each identified case, all slides of blocks designated by the radiologist as containing microcalcifications were pulled for review. Our protocol was to cut initially two levels separated by 50 microns. If no microcalcifications were detected an additional 10 levels each separated by 100 microns were examined. The level at which microcalcifications were first detected was recorded. Results (if a Case Study enter NA) The search revealed four-hundred and thirty-one specimens meeting study criteria. Four-hundred and fifteen of these samples contained microcalcifications on histologic examination. Probability of finding microcalcifications in the initial level was 0.629 and 0.935 in the first six levels. The incremental cost per calcification was 1.5 for the first level and 66.7 for the sixth level. The relative cost per calcification in level 6 was 44.5. Levels beyond level 6 rarely disclose microcalcifications. Conclusion 94% of microcalcifications documented by imaging were detected histologically in the first six levels using our protocol. The six-level protocol appears optimal for detection of microcalcifications. This study has significant implications for other specimen types. When a strong suspicion for a pathologic lesion is present on imaging but histologic sampling reveals no lesion, four further levels cut at 100 microns should be obtained.

Autoimmune Neutropenia of Infancy Is Almost Exclusively Caused By IgG Antibodies

Background The relevance of IgM antibodies in autoimmune mediated hemocytopenias remains a matter of debate. For autoimmune neutropenia, conflicting results were published. This study was performed as part of the Giessen Neutropenia Registry, which prospectively included children with suspected autoimmune neutropenia. Methods Children with suspected autoimmune neutropenia were prospectively enrolled and data central to their suspected diagnosis were collected over 3 years. Sera were tested for the presence of autoantibodies against neutrophils by granulocyte immunofluorescence test (GIFT) and granulocyte agglutination test (GAT). The presence of IgG and IgM antibodies was assessed in a subgroup of patients with positive initial GIFT in whom spontaneous remission of their neutropenia was documented. Results A total of 406 children were included in the study. A remission was reported for 114 patients during the study period. Of those, 96 children (84%) had an initial positive GIFT. Their median age at diagnosis was 11 months (7-17.5), and their mean neutrophil count was 293 (±267)/µL, ranging from 0 to 975. In total 75/96 (78%) of children had at least one documented infection at diagnosis. In 29/96 (30%), a bone marrow aspirate was available. At the documented time point of remission, children were 27 months (18-41) old. In the initial sample send for diagnosis, IgG antibodies against neutrophils were detected in 94/96 children (98%), and IgM antibodies were detected in 2/96 (2%). We did not observe children with autoantibodies of both Ig classes. Conclusion To our knowledge, this is the first study to demonstrate the contribution of IgG or IgM antibodies in a well-defined clinical cohort with a typical course including, spontaneous disease remission. IgG antibodies were present in 98%. Only very rarely, IgM antibodies can be detected. We conclude that in general, screening for IgG autoantibodies is appropriate as a first diagnostic step. In cases with strong clinical suspicion but negative GIFT with anti-IgG, anti-IgM testing may be considered.

2718. Prevalence of Infections Following Anti-CD30 Targeted Chimeric Antigen Receptor T-cell Therapy for Relapsed and Refractory Lymphoma

Abstract Background Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of relapsed or refractory hematologic malignancies. Clinical trials have demonstrated anti-CD30 CAR T-cell efficacy in patients with CD30+ malignancies such as Hodgkin lymphoma, but little is known about post-treatment infections. Understanding infections in this context is necessary to inform antimicrobial prophylaxis and treatment guidelines. The purpose of this project was to provide the first known characterization of infections in patients who received anti-CD30 CAR T-cell therapy. Methods Ours was a retrospective cohort study of adult patients receiving anti-CD30 CAR-T cells between 2016 and 2021. For the year following therapy, we tracked viral, bacterial, and fungal infections with both a microbiological confirmation or strong clinical suspicion of infection. Results 62 patients received anti-CD30 CAR T-cell therapy during the study period. The median age was 40.9 years, 35.5% were female, 79.0% were of European ancestry, and 93.5% were Not Hispanic or Latino. 77.4% of patients’ primary malignancy was Hodgkin’s lymphoma. 56.5% received Fludarabine and Bendamustine as the preparatory regimen (Table I). Five patients were lost to follow-up and were not included in infection analysis. Overall, there were 37 infectious events in 25 patients (25/57, 43.9%). 43.2% of infections happened within 30 days, 35.1% within 31-90 days, and 21.6% within 90 days to one year. Viral infections were the most common overall (48.6%) and within each time period (Table II). The most common pathogen was Varicella Zoster (10.8%); none of these patients were on valacyclovir prophylaxis at the time of infection. The lung was the most common site of infection overall (29.7%) (Figure 1). Death due to infection was seen in one patient during the study period. Table showing the demographic characteristics of the study cohort including age, gender, race, ethnicity, malignancy, and preparatory regimen. Table capturing infection characteristics including total infections, patients with an infection, and microbiology of the infections overall and broken down by time period.Figure 1.Infectious Organisms and Site of Infection Two bar charts with the top bar chart demonstrating the frequency of each infectious organism and the bottom bar chart demonstrating the frequency of each infection site. Conclusion Infections following anti-CD30 CAR T-cell therapy are most common within 30 days following therapy though risk persists through one-year post-therapy. Viral infections were the most prevalent which differs from reports with anti-CD19 CAR T-cell therapy in which bacterial infections were most common. These results may inform future antimicrobial guidelines for patients receiving these therapies. Disclosures Manish K. Saha, MD, Novavax: Stocks/Bonds Melody Smith, MD, MS, BMS: Advisor/Consultant

Lung Abnormalities in Liver Cirrhosis

Regardless of preexisting lung illness, patients suffering from liver cirrhosis, especially decompensated liver cirrhosis can develop distinct pulmonary complications. Liver cirrhosis patients should be assessed for hepatopulmonary syndrome (HPS), portopulmonary hypertension (PoPH), hepatic hydrothorax (HH) and spontaneous bacterial empyema (SBEM) which are the most clinically significant pulmonary consequences, in particular when dyspnea develops in conjunction with hepatic cirrhosis. These entities differ in terms of pathophysiology, clinical characteristics, diagnosis and suitable treatment options. This emphasize the need of specific diagnostic algorithm in liver cirrhosis patients presenting with dyspnea or other pulmonary symptoms. These pulmonary complications might be rare in patients with liver cirrhosis and portal hypertension but these complications might carry significant morbidity and mortality risks and, therefore, strong clinical suspicion is required to make an early accurate diagnosis. There are several medical therapies available for each condition in the multiple studies but most of the treatments and proceures doesn’t have significant benefit or have short lived benefit. The only treatment that changes the clinical prognosis of decompensated cirrhosis effectively in long term is liver transplantation. However liver transplantation also needs careful considerations as on some cases it might increase the risk of morbidity and mortality.
 
 Keywords: Cirrhosis Hepatis, Hepatopulmonary Syndrome, Portopulmonary Hypertension, Hepatic Hydrothorax, Spontaneous Bacterial Empyema

OGBN P12 Use of Computed Tomographic Scan in Diagnosis and Management of Acute Pancreatitis; A Clinical Audit

Abstract Background Acute pancreatitis is a frequently encountered emergency surgical condition, with computed tomography (CT) scans being commonly used for diagnosis and management. This audit was done in an NHS Hospital in Northwest, England with the aim to assess the utilization of CT scans in the diagnosis and management of acute pancreatitis in accordance with local policy. Methods Data were collected from all patients admitted with acute pancreatitis between October 2022 and March 2023. The focus of the investigation was on patients who underwent CT scans, with the objective of identifying the indications for their usage. Results The audit included a total of 53 patients (mean age 52.75 years, almost equal gender distribution). 64.2% had clinical pancreatitis (typical symptoms and diagnostic amylase levels), while 35.8% did not. 42 patients (79.2%) underwent CT scans. Of these scans, 42.9% were performed in patients without diagnostic amylase levels, 14.3% to rule out complications after 3 days, 9.5% due to a history of pancreatic complications, 1 was based on strong suspicion of another pathology, and another for diagnosing a common bile duct stone in a patient with an MRI incompatible pacemaker. Furthermore, 12 (28.5%) of the scans done were considered unnecessary. Conclusions The findings indicate that approximately 8 out of 10 patients with acute pancreatitis underwent at least one CT scan during their hospitalization. However, a significant proportion (28.5%) of these scans were deemed unnecessary.

Upper Urinary Tract Urothelial Carcinomas: Benefits of Diagnostic Ureteroscopy and Results of Conservative Treatment

Upper urinary tract urothelial carcinomas (UTUC) are rare and predominantly male. They may be multifocal in around 30% of cases. They are of particular interest because of the difficulties involved in their diagnosis. We report a series of 08 patients collected in the urology department of the Hôpital Nord Franche-Comte (HNFC) in Trevenans between 01/2019 and 03/2022. There were 05 men (62.5%) and 03 women (37.5%) with an average age of 70.85 years. Clinical symptoms were dominated by low back pain in 04 patients (50%), haematuria in 2 patients (25%), and a combination of low back pain and haematuria in 1 patient (12.5%). The finding was fortuitous in 1 patient (12.5%). The uroscanner performed in all our Patients revealed ureteral lesions in 7 patients (87.5%), a combination of ureteral lesion and ureteropyelocalic dilatation (UPD) in 4 patients (50%) and a normal uroscanner in 1 patient (12.5%). Ultrasound was not performed in any of our patients. Cystoscopy revealed an infracentimetric polyp at the level of the bladder dome in 3 patients (37%), including 1 patient undergoing surveillance for UTUC and who had no history of bladder tumour; the other 2 were already being monitored for bladder tumour; a trigonal polyp measuring approximately 3cm in 1 patient (12.5%) who had a history of bladder tumour, an infracentimetric floor polyp in 1 patient (12.5%) who had no history of bladder tumour, and normal cystoscopy in the other 3 (37.5%). Ureteroscopy revealed a papillary lesion measuring approximately 1cm in the middle calyx of the right kidney in 1 patient (12.5%), a lesion of the pelvic ureter in 4 patients (50%) measuring approximately 1.5cm, 2cm, 3cm in the first 3 patients and a lesion occupying the entire pelvic ureter in the 4th patient; a lesion of the iliac ureter in 3 patients (37.5%) whose sizes are approximately 1cm, 2cm, and 4cm. Urine cytology showed a strong suspicion of a high-grade urothelial lesion in 2 patients (25%), an appearance of a low-grade ..

Kewenangan Penyidik Polri untuk Melakukan Penahanan Tersangka Pelaku Tindak Pidana dalam Proses Peradilan Pidana


 
 
 
 
 
 
 
 
 
 
 
 
 In the criminal justice system, the police are the "gateway" for justice seekers. This is where things started. This initial position puts the police at a disadvantage. As an investigator the police must make arrests (when necessary) detentions, which means the police must have a strong suspicion that the person is the perpetrator of the crime. Detention can be done if it is deemed necessary. As stated in Article 1 Point 21 of the Code of Criminal Procedure: "Detention is the placement of suspects or defendants in certain places by investigators, public prosecutors, or judges with their determination in the case and in the manner provided for in this law. Based on the results of the study, the author concludes that legal considerations of police investigators are authorized to detain suspected perpetrators of criminal acts, because the National Police as investigators in the investigation process have duties and obligations of their main duties and functions. In connection with these duties and obligations, the police have the authority as stipulated in: 1) Law Number 8 of 1981 concerning the Code of Criminal Procedure, namely the condition of subjective detention is a condition stemming from the assessment and concern of the investigator that if the defendant is not detained then the accused will run away, will damage or eliminate evidence, and will even repeat the crime; 2) Law Number 2 of 2002 concerning the National Police of the Republic of Indonesia; and clearly about how the management of criminal investigations must be carried out by the police as stipulated in Perkapolri No. 14 of 2012 concerning Management of Criminal Investigations
 
 
 
 
 
 
 
 
 
 
 
 

Transgluteal Ultrasonography in Spica Cast in the Post-reduction Assessment of Hip Developmental Dysplasia

Concentric circle reduction is one of the outcomes after reduction of developmental dysplasia of the hip (DDH). Radiography and magnetic resonance imaging (MRI) are used to confirm the reduction results. In this study, we evaluated the reduction results of the coronal section of the hip using transgluteal ultrasonography. We enrolled 46 children admitted to our hospital for closed or open reduction plaster fixation of DDH between January 2021 and December 2022. Thirty-eight patients had unilateral DDH, and eight patients had bilateral DDH. Transgluteal ultrasonography, radiography and MRI were done on the patients during the 7 d after reduction, and the results were interpreted by different radiologists. The covering of the femoral head and the distance between the medial margin of the femoral head and the acetabulum (HSD) were measured after calculating the maximum coronal surface of the iliac bone. MRI is regarded as the gold standard for determining hip reduction or dislocation. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasound and radiography were determined and compared. The sensitivity, specificity, PPV and NPV of transgluteal ultrasonography were 100% (confidence interval [CI]: 69.2%-100%), 97.7% (CI: 88%-99.9%), 90.9% (CI: 59%-98.6%) and 100%, respectively, higher than those of radiography, which were 50% (CI: 18.7%-81.3%), 86.4% (CI: 72.6%-94.8%), 45.5% (CI: 24%-68.7%) and 88.4% (CI: 80.2%-93.5%), respectively. Ultrasonography had a higher sensitivity (100% vs. 50%, p < 0.01) and positive predictive rate (90.9% vs. 45.5%, p < 0.01) than radiography. Ultrasonography revealed that a distance between the head and socket (HSD) >8 mm indicated a strong suspicion for a poor reduction. Transgluteal coronal ultrasound scan with semiquantitative assessment of acetabular femoral head coverage and measurement of HSD can effectively monitor the reduction relationship between the two in children after DDH reduction.

Primary Parotid Tuberculosis in a Toddler

Tuberculosis (TB) of the parotid gland is a rare disease and occurs less frequently in children. Re-emergence is seen amongst immunocompromised individuals whose diagnosis may be overlooked, leading to unnecessary surgery. Diagnosis is challenging in the absence of systemic constitutional symptoms and depends mainly on the treating physician having a strong suspicion. We report a rare extrapulmonary manifestation of TB involving the parotid gland in an otherwise immunocompetent child. A 2-year-old girl presented with a mass in the right parotid region that had been present for 3 months. A similar swelling was treated with an antibiotic 3 months prior, but it recurred. The mass was painful, firm, erythematous, and located in the infra-auricular region. Symptoms persisted after 2 courses of antibiotics, after which ultrasonography was performed and the intra-parotid collection was aspirated, which was positive for acid-fast bacilli (AFB). The patient was placed on anti-TB treatments. Although uncommon, TB should be considered in patients with a solitary mass in the parotid gland to avoid unnecessary surgery.

SCRUB TYPHUS - A RE-EMERGING DISEASE: ESTIMATING THE BURDEN AND OUTCOME OF SCRUB TYPHUS IN A TERTIARY CARE CENTRE

Background: Scrub typhus is regarded as an important cause of acute febrile illness. If not diagnosed early, it is often tends to be fatal. Methods: A Prospective Observational study was carried out among patients reporting with fever in a tertiary care hospital at Delhi. Weil Felix test and rapid test for scrub typhus was performed on the patient samples. Results: A total of 265 cases were screened for typhus group of fever, of these 26 (9.1%) patients (18 males and 8 females) were diagnosed having rickettsial fever. Out of these, 24 (92.3%) were diagnosed having scrub typhus fever. Conclusions:In present study, we observed 9.1% seropositivity in acute febrile illness. We conclude that a simple Weil Felix test should be included in routine workup of fever cases and a strong suspicion should be there where other laboratory tests remain inconclusive in endemic areas like Delhi-NCR.

Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis.

Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.

SAT311 A Time And Place For Metyrosine: Successful Treatment Of A Pheochromocytoma Presenting With Hypotension And Multisystem Organ Failure

Abstract Disclosure: R. Shafiq: None. J. Giordano: None. Pheochromocytomas are rare neuroendocrine catecholamine-secreting tumors. The surgical excision of pheochromocytoma is definitive management which requires presurgical preparation with an alpha blocker, beta blocker, and sometimes metyrosine to reduce perioperative hemodynamic instability. We present a case of pheochromocytoma complicated with acute on chronic renal failure and acute on chronic heart failure with hypotension requiring metyrosine in presurgical preparation due to hypotension and intolerance to alpha-blocker with successful surgical excision of the tumor. Case: 67 yo M admitted for acute on chronic heart failure and acute on chronic renal failure. He was noted to have an incidental right adrenal mass of 4.3 x 4.5 cm on the CT chest. He denied any prior history of hypertension, episodes of flushing, sweating, palpitations, headaches, or any family history of adrenal malignancies. His labs were consistent with significantly elevated plasma metanephrines to 4.5 nmol/L (normal range &amp;lt; 0.5 nmol/L) and normetanephrine 36 nmol/L (normal range &amp;lt; 0.9 nmol/L). Levels were repeated with slight worsening of metanephrines to 5.6 and normetanephrine to 42. He was hypotensive on presentation initially on milrinone drip that was slowly tapered off. His echo on admission showed left ventricle global hypokinesis with EF 25-30%. He had a worsening renal function on admission and required a few dialysis sessions before being referred to our hospital. He had an MRI adrenal done w/o contrast in the setting of renal failure with a heterogenous mass concerning for pheochromocytoma. PET CT was done which was negative for metastatic disease. Due to strong suspicion of uncontrolled pheochromocytoma as a cause of his heart failure and acute on chronic renal failure, the team and patient opted for unilateral adrenalectomy. He was started on metyrosine pre-surgically as he could not tolerate alpha blockade due to hypotension. His metanephrine levels improved from 5.6 to 1.8 and normetanephrine from 43 to 15 with metyrosine prior to surgery. He had a successful right adrenalectomy and pathology confirmed pheochromocytoma. Of note, he had a history of diabetes with uncontrolled hyperglycemia during admission. Hyperglycemia resolved after adrenalectomy. His plasma metanephrine levels normalized post-adrenalectomy and remained normal on the follow-up visit. Conclusion: Preoperative medical stabilization is a crucial step before surgical resection of pheochromocytoma that traditionally includes an alpha blocker followed by a beta-blocking agent to reduce intra-operative hypertensive crisis. Metyrosine is an often-overlooked agent due to cost, however, should remain in our armamentarium for pheochromocytoma crisis complicated with hypotension when the patient is unable to tolerate an alpha-blocking agent. Presentation: Saturday, June 17, 2023

SAT325 Recurrent Pericardial Effusion As Initial Presentation Of Primary Adrenal Insufficiency

Abstract Disclosure: S. Ward: None. A.L. Champion: None. A. Mrkaic: None. Recurrent Pericardial Effusion as Initial Presentation of Primary Adrenal Insufficiency: Background: Primary adrenal insufficiency (PAI) is a rare but serious endocrinopathy. High clinical suspicion is important to avoid delay in diagnosis and treatment. We present a rare case of recurrent pericardial effusion as initial presentation. Clinical Case: 63 year old male with hypertension and diabetes presented to ED complaining of SOB and chest pain. Workup revealed pericardial effusion causing cardiac tamponade treated with emergent pericardiocentesis. He was admitted to ICU for hypotension. He was also diagnosed with COVID-19 and acute kidney injury. Labs showed hyperkalemia ranging from 5.3 to 7.2 mmol/l (n= 3.5-5.1 mmol/l) and hyponatremia 132 mmol/L (n= 136-145 mmol/L). He was started on dexamethasone for COVID-19 infection. Etiology of pericardial effusion was unclear; infectious disease workup was unremarkable, cytology showed no malignant cells, autoimmune panel was negative. Initial echo showed EF &amp;gt;55%. After initiation of steroids, symptoms improved with normalization of electrolytes and improvement of hypotension, however was discharged on midodrine 2.5 mg TID. Seven days after discharge patient called 911 complaining of worsening shortness of breath. He was found to be severely hypotensive with BP 67/40. Echo showed moderate to large pericardial effusion causing tamponade. Emergent pericardial window was performed. Labs showed hyponatremia 123 mmol/L and potassium ranging from 4.9-5.4 mmol/L. Patient remained hypotensive requiring pressors despite pericardial effusion drainage. With persistent hypotension, hyperkalemia, and hyponatremia there was strong suspicion for adrenal insufficiency and workup was consistent with PAI. Labs showed 8:00 am cortisol 2.7 ug/dl (n= 3.7-19.4 ug/dl), ACTH 256.0 pg/ml (n=7.2-63.3pg/ml), aldosterone &amp;lt;1.0 ng/dL, renin 4.216 ng/mL/hr (n= 0.167-5.380 ng/mL/hr). Due to his critical illness patient was started on stress dose hydrocortisone 50 mg Q6 hr. With initiation of steroids, hyponatremia, hypokalemia, and hypotension resolved. Patient was weaned to physiological doses of hydrocortisone and started on fludrocortisone at time of discharge. Conclusion: Timely diagnosis of PAI is essential and can be lifesaving, if untreated it can lead to adrenal crisis with high mortality. Having a high clinical suspicion is crucial to a prompt diagnosis. Pericardial effusion should prompt clinical suspicion for PAI as multiple cases have now been reported in the literature. Our patient has multiple potential causes of pericardial effusion including PAI, acute kidney injury, and COVID-19 infection. Although we cannot show definitive causation from PAI, it most certainly contributed and prompt diagnosis and treatment may have prevented recurrence. It is important to raise awareness of PAI as a differential in pericardial effusion. Presentation: Saturday, June 17, 2023

Celestial Variability and Keats's ‘Bright star’

Early in his career the astronomer William Herschel argued that the appearance of ‘so many changes among the stars’ – stars materialising out of nowhere and stars gradually vanishing, stars fluctuating in brightness and stars changing position – ‘should cause a strong suspicion that most probably every star in the heaven is more or less in motion’. Given his knowledge of modern astronomy, Keats's plea to be as ‘stedfast’ as the bright star might be considered deliberately retrograde: the aesthetic privileging of an ideal by a sky-gazing lover indifferent to empirical science. This essay argues, on the contrary, that the ‘Bright star’ sonnet seizes upon a figurative paradox produced in a period of epistemological transition. The indeterminacy of the bright star image introduces an affective dimension to the sonnet more in keeping with its Petrarchan roots and captures an essential quality of even steadfast lovers: changeability.