Underreported Cause Research Articles

EVALUATION OF KNOWLEDGE, ATTITUDE, AND PRACTICE ABOUT PHARMACOVIGILANCE AMONG NURSING STAFF AT TERTIARY CARE TEACHING HOSPITAL

Objectives: The primary objective of this study was to evaluate the knowledge, attitude, and practice of nursing staff about pharmacovigilance and adverse drug reactions (ADRs) reporting in a tertiary care teaching hospital. The secondary objective was to assess the causes of underreporting of ADRs. Methods: A cross-sectional questionnaire-based study was carried out using a pre-designed structured questionnaire, adapted from previous studies and validated internally among the members of the pharmacovigilance committee. This questionnaire was provided to the nurses of all wards and out-patient department in a tertiary care teaching hospital of Gujarat, after taking their written informed consent. The data were evaluated for further analysis. Results: Out of 309 participants, 73.38% had appropriate knowledge about pharmacovigilance and ADRs and 72.41% had a positive attitude toward the safety of drugs and reporting of ADRs. Out of 309 nurses, 55.34% of nurses came across an ADR and 3.56% of nurses had reported an ADR. According to the evaluated data, the reasons for underreporting of ADRs were lack of awareness, lack of time, and fear of legal implications. Out of all participants, 4.85% had attended ADR training/awareness sessions. Conclusion: In the present study, nursing staff at a tertiary care teaching hospital had good knowledge and positive attitude toward pharmacovigilance but at the same time application of the same was lacking. Exposure to awareness programs and seminars about pharmacovigilance and hands-on ADR training sessions can improve the practice of nurses about pharmacovigilance.

Intensive and critical care nurses patient safety, care quality, professional self-efficacy, and missed nursing care: Structural equation model analysis.

Globally, nurses' patient safety, care quality, and missed nursing care are well documented. However, there is a paucity of studies on the mediating roles of care quality and professional self-efficacy, particularly among intensive and critical care unit (ICCU) nurses in developing countries like the Philippines. To test a model of the interrelationships of patient safety, care quality, professional self-efficacy, and missed nursing care among ICCU nurses. A cross-sectional, correlational design study was used. ICCU nurses (n = 335) were recruited via consecutive sampling from August to December 2023 and completed four validated self-report scales. Spearman Rho, structural equation modeling, mediation, and path analyses were utilized for data analysis. The emerging model demonstrated acceptable fit parameters. Patient safety positively influenced care quality (β = .34, p = .002) and professional self-efficacy (β = .18, p = .011), while negatively affecting missed nursing care (β = -.34, p = .003). Care quality positively and negatively influenced professional self-efficacy (β = .40, p = .003) and missed nursing care (β = -.13, p = .003), respectively. Professional self-efficacy indirectly impacted missed nursing care (β = -.32, p = .003). Care quality (β = -.10, p = .003) and professional self-efficacy (β = .13, p = .003) showed mediating effects between patient safety and missed nursing care. ICCU nurses' care quality and professional self-efficacy are essential mediating factors that can bolster patient safety practices, hence reducing missed nursing care. Therefore, healthcare organizations, nurse managers, and policymakers should cultivate care quality and self-efficacy by creating support programs and providing a positive practice environment. Nurses and nurse supervisors could directly observe missed nursing care in the ICCU to understand its underreported causes.

The straight head of rectus femoris: An underdiagnosed cause of chronic pain post hip replacement

Groin pain following hip arthroplasty has a spectrum of aetiologies. Although mild post-operative pain at six months to a year is common, other causative factors should be considered where pain is severe or persistent. The rectus femoris (RF) muscle is the most common of the quadriceps tendons to be injured or strained. Pathologies are known to occur in athletic adults and children and include tendinopathy, tear, and avulsion, but the RF is rarely attributed to hip pain post-arthroplasty. However, tendinopathy may occur as a result of altered biomechanics and muscle loading. We performed a retrospective analysis of 100 patients, at our tertiary orthopedic hospital, who presented with chronic pain post hip arthroplasty. We identified three patients with RF straight (direct) head tendinopathy and one patient with RF straight (direct) head calcific tendinopathy. Established causes of chronic post-operative pain include septic/aseptic loosening, pseudotumor, iliopsoas bursitis/impingement, and bursitis. In this report, we describe the scanning technique, sonographic appearances, and our institutional experience of post-arthroplasty pathologies of the RF straight (direct) head which is an underreported cause of chronic pain following hip replacement. We also recommend including the RF straight (direct) head in routine US protocols of the post-operative hip.

Spontaneous calcified cerebral emboli: a comprehensive review and proposed diagnostic criteria.

Spontaneous calcified cerebral emboli (SCCE) secondary to aortic valve calcification are a rare and underreported cause of acute ischaemic stroke. Only five cases of SCCE secondary to bicuspid aortic valve calcification have been reported in the literature. This review includes a unique case example of acute ischaemic stroke secondary to SCCE, as the first manifestation of a calcified bicuspid aortic valve. This is the first clinical case of calcified cerebral emboli (CCE) associated with borderzone infarction ('cortical ribbon sign'). Whilst previously assumed that most CCE are secondary to iatrogenic causes, recent literature suggests the majority of CCE are spontaneous and clinically silent. Despite CT imaging widely considered the 'gold standard' for diagnosis, CCE are frequently misdiagnosed and missed entirely. Misdiagnosis of CCE may have catastrophic consequences due to the high risk of recurrence and missed opportunity to prevent neurological disability and death. This review presents a revised CCE diagnostic criteria, using evidence that has emerged over the last decade to create both Compulsory (Major) and Supporting (Minor) criteria. Current CCE management is not evidence based and remains largely speculative. SCCE may be the first manifestation of cardiac or vascular disease and diagnosis should trigger aggressive treatment of emboligenic sources. Future epidemiological studies, analysing symptomatic and asymptomatic SCCE patients, would be beneficial in providing accurate quantification of disease burden. Other future research directions include exploring intracranial stenting for CCE revascularisation and cerebral intravascular lithotripsy.

Causes of Vision Loss Associated with Dengue Fever in Bihar, India - A Case Series.

The incidence and geographic distribution of dengue has increased dramatically in recent years across various parts of the world. Previously, ocular findings in dengue fever were considered rare. We report a spectrum of ocular manifestations presenting with vision loss in the last dengue epidemic in an eastern state of India. This is a retrospective interventional case series of patients with vision loss who were diagnosed with dengue eye disease in the 2022 epidemic. Systemic and ophthalmic examinations were completed on all patients and were analyzed. Fifteen patients had presented with vision loss. The mean age was 41.7 ± 10.8 years, and patients were mostly males. Three patients presented with panophthalmitis and orbital cellulitis. Eight patients were diagnosed with optic neuropathy. Four patients had macular involvement: macular chorioretinitis, macular subhyaloid hemorrhage, and macular hemorrhages in two patients. All patients with optic neuropathy gave a history of mild fever and had remained undiagnosed. The rest had been diagnosed with the more severe dengue hemorrhagic fever. Vision recovered partially or fully in patients with optic neuropathy and macular disease. No eye could be salvaged in any panophthalmitis patients. Thrombocytopenia (platelet count <100 × 109 per liter of blood) was significantly associated with ocular hemorrhage and panophthalmitis, but thrombocytopenia was not significantly seen in optic neuropathy. We conclude that optic neuropathy may be an underreported cause of vision loss in dengue fever. An eye examination is advocated in all patients with dengue eye disease.

Practicing Medicine Wisely: Routine Use of Urine Legionella in Suspicious Pneumonia - Are we Overdoing?

Legionella spp. is an underreported cause of Community Acquired pneumonia that affects significant population specially in urban areas and its prevalence is on an increasing trend. The routine practice of testing for urinary antigen of Legionella in all suspected cases of pneumonia is prevalent is resource rich western countries. Although several studies have shown no distinct advantage of performing routine urinary antigen testing, this practice continues to be preferred by clinicians. In this viewpoint, we have discussed the advantages and disadvantages of urinary antigen testing, its relevance in current practice and its impact on clinical outcomes.

Gastric ischemia as an under-reported cause of death in older people.

Acute gastric ischemia is a rare condition due to the rich vascular supply of the stomach. Here we present a case of fatal gastric ischemia associated with bowel ischemia, only diagnosed at autopsy, which was requested for the suspicion of medical liability. A complete post-mortem examination was conducted, along with a macroscopic analysis of the superior mesenteric artery and detailed histological analyses. Past clinical data was also reviewed. The macroscopic blackish discoloration of the stomach and the bowel, coupled with the presence of neutrophils in the mucosa and submucosal non-occlusive thrombi, were consistent with gastric and bowel ischemia, despite the presence of confounding putrefactive changes. The unique aspect of this case resides in the ante-mortem peculiar vascularization of the stomach, supplied by small collateral vessels. No mechanical occlusion was identified, and the cause of the ischemia was deemed as non-occlusive, likely due to systemic hypoperfusion. The analysis of clinical data and documentation of associated comorbidities are strongly recommended, especially when a rare cause of death is suspected. With the aging population, especially among women, and the prevalence of risk factors, the forensic pathologist could increasingly encounter rare cases of gastric ischemia.

Suicidal behavior and associated factors among holy water users at Northwest, Ethiopia, 2023: an institution based cross-sectional study.

Suicide is a serious cause of mortality that affects families, communities, and the entire country. Because of a lack of national systematic reporting for cause-specific mortality, a high level of stigma, and religious non-acceptance, suicidal behavior is an under-reported and concealed cause of death in the majority of low- and middle-income countries. The aim of this study was to assess the prevalence of suicidal behavior and associated factors among holy water users at the Andassa Saint George Monastery, 2023. An institution-based cross-sectional study was conducted at the Andassa Saint George Monastery from 5 April to 5 May 2023. A systematic random sampling method was utilized to select 423 study participants and the Suicidal Behaviors Questionnaire-Revised was used to assess suicidal behavior. The data were gathered using the epicollect5 software with a face-to-face interview method then exported to SPSS-25 for analysis. A binary logistic regression model was used and all variables in a bivariate analysis with a p-value of less than 0.25 were entered into a multivariable logistic regression model, and statistical significance was declared at a p-value of less than 0.05. The prevalence of suicidal behavior among holy water users was 9.7% (95% CI: 7.1-12.4). Being female [2.632 (1.206-5.748)], living alone [2.52 (1.06-5.97)], and having depression [3.03 (1.32-6.99)], epilepsy [3.82 (1.28-11.40)], and diabetes mellitus [3.37 (1.229-9.25)] were significantly associated with suicidal behavior. In this study, almost 1 in 10 had engaged in suicidal behavior in their lifetime. Several risk factors for suicidal behavior were identified, including being female, living alone, and having diabetes mellitus, epilepsy, and depression.

Biliary Leak from Ducts of Luschka: Systematic Review of the Literature

Injury to the Luschka ducts (LDs), also named “subvesicular” ducts, is an under-reported cause of biliary leak following laparoscopic cholecystectomy (LC). A systematic literature search according to PRISMA guidelines was conducted in PubMed, EMBASE and Cochrane Library including all publications that described a bile leak from an LD. A total of 136 articles were retrieved from the searched databases. After the removal of duplicates and non-eligible papers, 48 studies reporting 231 leaks were included: 20 (41.6%) case reports, 2 (4.3%) comparative studies, 7 (14.9%) meeting abstracts and 19 (40.4%) retrospective cohort articles. The rate of LD leak ranges from 0.05% to 1.9%, but injury to a duct of Luschka was the second most common cause of biliary leakage in all the cohort studies (5.5% to 41%). In 21 (43.7%) cases, the leak was successfully treated with a sphincterotomy through Endoscopic Retrograde Cholangiopancreatography (ERCP) plus or minus stenting, and in 12 (25%), re-laparoscopy was necessary.

Yersinia enterocolitica biovar 1A: An underappreciated potential pathogen in the food chain

Yersinia enterocolitica is an underreported cause of foodborne gastroenteritis. Little is known of the diversity of Y. enterocolitica isolated from food and which food commodities contribute to human disease. In this study, Y. enterocolitica was isolated from 37/50 raw chicken, 8/10 pork, 8/10 salmon and 1/10 leafy green samples collected at retail in the UK. Up to 10 presumptive Y. enterocolitica isolates per positive sample underwent whole genome sequencing (WGS) and were compared with publicly available genomes. In total, 207 Y. enterocolitica isolates were analyzed and belonged to 38 sequence types (STs). Up to five STs of Y. enterocolitica were isolated from individual food samples and isolates belonging to the same sample and ST differed by 0–74 single nucleotide polymorphisms (SNPs). Biotype was predicted for 205 (99 %) genomes that all belonged to biotype 1A, previously described as non-pathogenic. However, around half (51 %) of food samples contained isolates belonging to the same ST as previously isolated from UK human cases. The closest human-derived isolates shared between 17 and 7978 single nucleotide polymorphisms (SNPs) with the food isolates. Extensive food surveillance is required to determine what food sources are responsible for Y. enterocolitica infections and to re-examine the role of biotype 1A as a human pathogen.

Integrated omics analyses clarifies ATRX copy number variant of uncertain significance.

Partial duplications of genes can be challenging to detect and interpret and, therefore, likely represent an underreported cause of human disease. X-linked dominant variants in ATRX are associated with Alpha-thalassemia/impaired intellectual development syndrome, X-linked (ATR-X syndrome), a clinically heterogeneous disease generally presenting with intellectual disability, hypotonia, characteristic facies, genital anomalies, and alpha-thalassemia. We describe an affected male with a de novo hemizygous intragenic duplication of ~43.6 kb in ATRX, detected by research genome sequencing following non-diagnostic clinical testing. RNA sequencing and DNA methylation episignature analyses were central in variant interpretation, and this duplication was subsequently interpreted as disease-causing. This represents the smallest reported tandem duplication within ATRX associated with disease. This case demonstrates the diagnostic utility of integrating multiple omics technologies, which can ultimately lead to a definitive diagnosis for rare disease patients.

RNA sequencing resolves novel DYNC2H1 variants causing short-rib thoracic dysplasia type 3: Case report.

Intronic variants outside the canonical splice site are challenging to interpret and therefore likely represent an underreported cause of human disease. Autosomal recessive variants in DYNC2H1 are associated with short-rib thoracic dysplasia 3 with or without polydactyly (SRTD3), a clinically heterogeneous disease generally presenting with short ribs, shortened tubular bones, narrow thorax and acetabular roof anomalies. We describe a case of SRTD3 with compound heterozygous frameshift and intronic variants and highlight the essential role of RNA sequencing (RNA-Seq) in variant interpretation. Following inconclusive clinical genetic testing identifying a likely pathogenic frameshift variant and an intronic variant of uncertain significance (VUS) in DYNC2H1 in trans, the family enrolled in the Care4Rare Canada research program, where RNA-Seq studies were performed. The proband presented with post-axial polydactyly of all four limbs, a significantly small chest with a pectus excavatum and anterior flaring of the ribs. RNA-Seq investigations revealed a novel splice junction as a result of the intronic VUS and significantly decreased DYNC2H1 gene expression in the proband. This case demonstrates the diagnostic utility of RNA-Seq for variant interpretation following inconclusive clinical testing, which can ultimately lead to diagnosis for patients with rare disease.

Aetiology, pathogenesis and management of neuropathic itch: A narrative review with recent updates.

Neuropathic itch is a relatively common yet under-reported cause of systemic pruritus. It is a debilitating condition often associated with pain, which impairs the patient's quality of life. Although much literature exists about renal and hepatic pruritus, there is a dearth of information and awareness about neuropathic itch. The pathogenesis of neuropathic itch is complex and can result from an insult at any point along the itch pathway, ranging from the peripheral receptors and nerves until the brain. There are several causes of neuropathic itch, many of which do not produce any skin lesions and are thus, often missed. A detailed history and clinical examination are necessary for the diagnosis, while laboratory and radiologic investigations may be needed in select cases. Several therapeutic strategies currently exist involving both non-pharmacological and pharmacological measures, the latter including topical, systemic, and invasive options. Further research is ongoing to clarify its pathogenesis and to design newer targeted therapies with minimal adverse effects. This narrative review highlights the current understanding of this condition, focusing on its causes, pathogenesis, diagnosis, and management, along with newer investigational drugs.

Cardiovascular events among recipients of hematopoietic stem cell transplantation-A systematic review and meta-analysis.

Cardiovascular diseases are an emerging cause of mortality and morbidity in survivors of hematopoietic stem cell transplantation (HSCT); however, the incidence of cardiovascular events (CVEs) in this population is not well described. This systematic review summarizes the evidence on the incidence of CVEs in HSCT recipients. Medline and Embase were searched from inception to December 2020. Inclusion criteria were cohort studies and phase 3 randomized controlled trials that reported CVEs among adults who underwent HSCT for hematological malignancies. After reviewing 8386 citations, 57 studies were included. The incidence of CVEs at 100 days was 0.19 (95% CI: 0.17-0.21) per 100 person-days after autologous HSCT and 0.06 (95% CI: 0.05-0.07) per 100 person-days after allogeneic HSCT. This higher incidence after autologous HSCT was driven by reports of arrhythmia from one population-based study in patients with multiple myeloma. The incidence of long-term CVEs was 3.98 (95% CI; 3.44-4.63) per 1000 person-years in survivors of autologous HSCT and 3.06 (95% CI; 2.69-3.48) per 1000 person-years in survivors of allogeneic HSCT. CVEs remain an important but under-reported cause of morbidity and mortality in recipients of HSCT. Future studies are required to better understand the incidence and risk factors for CVEs in HSCT recipients.

Using Entamoeba muris To Model Fecal-Oral Transmission of Entamoeba in Mice.

There are several Entamoeba species that colonize humans, but only Entamoeba histolytica causes severe disease. E. histolytica is transmitted through the fecal-oral route to colonize the intestinal tract of 50 million people worldwide. The current mouse model to study E. histolytica intestinal infection directly delivers the parasite into the surgically exposed cecum, which circumvents the natural route of infection. To develop a fecal-oral mouse model, we screened our vivarium for a natural murine Entamoeba colonizer via a pan-Entamoeba PCR targeting the 18S ribosomal gene. We determined that C57BL/6 mice were chronically colonized by Entamoeba muris. This amoeba is closely related to E. histolytica, as determined by 18S sequencing and cross-reactivity with an E. histolytica-specific antibody. In contrast, outbred Swiss Webster (SW) mice were not chronically colonized by E. muris. We orally challenged SW mice with 1 × 105 E. muris cysts and discovered they were susceptible to infection, with peak cyst shedding occurring between 5 and 7 days postinfection. Most infected SW mice did not lose weight significantly but trended toward decreased weight gain throughout the experiment compared to mock-infected controls. Infected mice treated with paromomycin, an antibiotic used against noninvasive intestinal disease, do not become colonized by E. muris. Within the intestinal tract, E. muris localizes exclusively to the cecum and colon. Purified E. muris cysts treated with bovine bile in vitro excyst into mobile, pretrophozoite stages. Overall, this work describes a novel fecal-oral mouse model for the important global pathogen E. histolytica. IMPORTANCE Infection with parasites from the Entamoeba genus are significantly underreported causes of diarrheal disease that disproportionally impact tropical regions. There are several species of Entamoeba that infect humans to cause a range of symptoms from asymptomatic colonization of the intestinal tract to invasive disease with dissemination. All Entamoeba species are spread via the fecal-oral route in contaminated food and water. Studying the life cycle of Entamoeba, from host colonization to infectious fecal cyst production, can provide targets for vaccine and drug development. Because there is not an oral challenge rodent model, we screened for a mouse Entamoeba species and identified Entamoeba muris as a natural colonizer. We determine the peak of infection after an oral challenge, the efficacy of paromomycin treatment, the intestinal tract localization, and the cues that trigger excystation. This oral infection mouse model will be valuable for the development of novel therapeutic options for Entamoeba infections.

Recurrent Thrombosis in a Lady: Is there a Missed Connection?

Background: COVID19 infection is a recognized risk factor for systemic thrombosis. There have been few case reports about thrombosis following COVID19 vaccination. Case presentation: A middle aged lady presented with acute pulmonary thromboembolism, with history of cerebral sinovenous thrombosis 3 weeks back. Thrombophilia workup and DVT screen was negative, but on reviewing history she had received CoviShield vaccine 1 week prior to the CSVT. Conclusion: COVID19 vaccine use is an under-reported cause for systemic thrombosis. However, larger studies are required to establish the mechanism and causal-effect relationship.

ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICES OF PHARMA-COVIGILANCE PRESCRIBERS AT LIAQUAT UNIVERSITY HOSPITAL HYDERABAD, PAKISTAN

Spontaneous reporting is an important tool in pharmacovigilance. Underreporting of adverse drug reactions (ADRs) is a common problem. In order to improve the ADR reporting, it is essential to improve the knowledge, attitude and practice (KAP) of the healthcare professionals. Various factors are related with the KAP of under reporting of ADR. Objectives: The present study was undertaken to evaluate the KAP regarding ADR reporting of among the prescribers of a tertiary care teaching hospital with ADR monitoring Liaquat University hospital, Hyderabad to get insight into the causes of underreporting of ADR. It was questionnaire based cross sectional study. A questionnaire (knowledge -1-10, attitude -11-23 and practice -24-28) was administered to 200 prescribers. The questionnaire was assessed regarding the ADR reporting. Microsoft excels worksheet and chi-square test was used for statistical analysis. A total 170(85%) prescribers completed and returned the questionnaire. Regarding definition of pharmacovigilance, specific aim of pharma covigiilance, functions of ADR monitoring center (AMC), 93%, 79% and 51.8% participants respectively could answer correctly. Only 54% respondents opined correctly that reporting of ADR is voluntary. 76.5% participants know the existence of AMC in the institution. 27.6% participants expressed that ADR reporting will generate extra work. 22.4% of participants reported ADR. Regarding reasons of under reporting many factors has been pointed out namely “do not know how to report”, “lack of knowledge about reporting procedure”, “not knowing where to report”, lack of time to report and lack of access to ADR form. The medical professionals are aware and have partial knowledge about ADRs. However, under reporting and lack of knowledge about reporting system are clearly evident. There is great need of creating awareness about ADR reporting system. Regular sensitization program to motivate the medical professionals may improve the ADR reporting. Keywords: Adverse drug reactions (ADR), Knowledge, Attitude and practice, Pharmacovigilance, Spontaneous reporting

ODP148 GENDER AFFIRMING HORMONE THERAPY AND SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is an important and underreported cause of acute coronary syndrome in women. SCAD has been linked to arteriopathy, pregnancy, as well as hormone replacement therapy in cisgender patients. There is a scarcity of data on the long-term cardiovascular effects of gender affirming hormonal therapy (GAHT) with estrogen. Observational studies have shown increased thromboembolic disease and cardiovascular events in transwomen on estrogen, with oral synthetic or oral combined equine estrogens showing a higher association versus transdermal formulations, however there had been no reports of SCAD in transgender patients on GAHT. Clinical Case A 37-year old transwoman with a history of gender affirming orchiectomy on GAHT with sublingual estradiol 2 mg BID presented with typical symptoms of acute coronary syndrome. No prior history of chest pain. No personal history or family history of cardiovascular disease or risk factors. Initial Troponin I was 9.52 ng/dl (&amp;lt;0. 04 ng/dl), ECG with non-specific ST-changes. A transthoracic echocardiogram showed hypokinesis of the mid anterior and lateral wall. She underwent urgent cardiac catheterization, found to have SCAD of her ramus intermedius. Given the size of the lesion and wall motion abnormalities, a cutting balloon was used to inflate the lesion, and she remained chest pain free during the hospitalization. She was started on Aspirin, Clopidogrel, and Metoprolol. Sublingual estradiol was determined to be her only predisposing risk factor and therefore it was held during her hospitalization and during the lesion healing period, with plans to change to a constant transdermal estrogen patch in the primary care setting. Discussion This is the first case report showing an association of estrogen GAHT and SCAD in a transwoman. SCAD has been observed to occur more often in cisgender women during the late luteal phase and post-partum period, raising the hypothesis that estrogen level fluctuations could potentially play a role. Sublingual estradiol has been shown to have higher peak and trough serum concentration compared to oral estradiol. Research is needed in this area and on the potential adverse cardiovascular effects of GAHT and whether route of estrogen administration plays a role. We support transdermal estradiol in transwomen with or at risk of cardiovascular disease, and close monitoring of serum levels, as well as aggressive treatment of cardiovascular risk factors. Presentation: No date and time listed

S188 Idiopathic Myointimal Hyperplasia of Mesenteric Veins: A Systematic Review and Individual Patient Regression Analysis

Introduction: Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is an uncommon cause of colonic ischemia for which surgical treatment is recommended. We describe the clinical, radiologic and endoscopic findings in IMHMV patients to provide clinicians with a framework for the identification of this rare disease. Methods: We performed a systematic review of seven databases for cases of IMHMV and identified additional cases from Yale New Haven Hospital records. To identify features specifically associated with colonic ischemia due to IMHMV, we performed multivariate logistic regression analysis incorporating data from a large, well-characterized multicenter cohort of biopsy-proven ischemic colitis (n=923). Results: A total of 123 patients with IMHMV were identified from 58 publications and 3 unpublished cases at Yale New Haven Hospital (80% male, mean age 53, 56% Caucasian). Symptoms at presentation were most commonly abdominal pain (87%) and diarrhea (67%). The most affected areas were the sigmoid colon (89%) and rectum (66%). Median time from symptom onset to diagnosis was 4 months. Complications, including obstruction and perforation due to diagnostic delay occurred in 33% of patients. The most common radiologic feature was thickening of the affected segment of colon (97%). Anatomic vascular abnormalities including non-opacification of the inferior mesenteric vein were observed in 38% of patients. 97% of patients ultimately underwent curative segmental colectomy. Mean follow-up time was 23.6 months. Compared to biopsy-proven non-IMHMV colonic ischemia, IMHMV was significantly associated with younger age (p=0.010), male sex (p=0.002), rectal involvement on imaging (p=0.027) and on endoscopic evaluation (p=0.004), mucosal ulcerations on endoscopy (p=0.049) and absence of rectal bleeding on presentation (p< 0.001) (Table). Conclusion: IMHMV is a rare, underreported cause of colonic ischemia that predominantly involves the left colon. Using the largest IMHMV cohort to date and comparing to a multicenter cohort of patients with ischemic colitis, we identify clinical, endoscopic, and radiologic characteristics of this entity. Our findings suggest younger age, rectal involvement, and absence of rectal bleeding as clinical features to help identify select patients presenting with colonic ischemia as having higher likelihood of IMHMV and therefore consideration of upfront surgical management. Table 1. - Clinical, endoscopic, and radiologic findings associated with IMHMV associated colonic ischemia Variable # patients IMHMV # patients Non-IMHMV P value Demographics Age 85 55.5 (17.0) 922 69.5 (13.2) < 0.001 Male sex 85 78.8% (67) 918 28.7% (265) < 0.001 Clinical Presentation Abdominal pain 85 84.7% (72) 918 82.6% (758) 0.764 Rectal bleeding 85 57.6% (49) 913 76.2% (696) < 0.001 Pain without bleeding 85 35.3% (30) 911 22.7% (207) 0.011 Bleeding without pain 85 8.2% (7) 911 18.2% (166) 0.017 Non-bloody diarrhea 85 24.7% (21) 911 11.0% (100) < 0.001 Clinical Comorbidities Hypertension 61 21.3% (13) 921 75.1% (692) < 0.001 Diabetes mellitus 61 13.1% (8) 921 30.0% (276) 0.005 Stroke 61 4.9% (3) 920 10.8% (99) 0.193 Hypercoagulability 61 6.6% (4) 768 1.0% (8) 0.008 Multivariate logistic regression Variable aOR 95% CI P value Age, per year 0.941 0.919 – 0.964 0.010 Sex (Male) 10.10 4.71 – 21.67 0.002 Rectal bleeding on presentation 0.006 0.001 – 0.025 < 0.001 Non-bloody diarrhea on presentation 1.46 0.60 – 3.55 0.673 Diabetes mellitus 0.569 0.249 – 1.350 0.494 Rectal involvement on imaging 6.71 2.84 – 15.85 0.027 Right-sided involvement on endoscopy 0.620 0.213 – 1.806 0.655 Rectal involvement on endoscopy 12.61 5.22 – 30.51 0.004 Mucosal ulcerations on endoscopy 4.06 1.99 – 8.25 0.049 Baseline characteristics and regression analysis of IMHMV and non-IMHMV patients included in the final multivariate model. Number of patients included in the analysis are indicated. Continuous variables presented as mean and standard deviation. Categorical variables are presented as proportion and number of individuals. aOR = adjusted odds ratio. 95% CI = 95% confidence interval.

Urinothorax: an under-reported cause of pleural effusions.

Urinothorax: an under-reported cause of pleural effusions.