Stable Vital Signs Research Articles

Postoperative Nausea and Vomiting According to Target-Controlled or Manual Remifentanil Infusion in Gynecological Patients Undergoing Pelviscopic Surgery: A Randomized Controlled Trial

We compared the incidence of postoperative nausea and vomiting (PONV) and postoperative outcomes, according to the remifentanil infusion method, during surgery in patients with a high-risk of PONV. Ninety patients undergoing elective gynecological pelviscopic surgery were randomly allocated to either target-controlled infusion (TCI, T) or manual (M) infusion. The primary outcome was the incidence of PONV until postoperative day (POD) 2. The secondary outcomes were perioperative heart rate (HR), blood pressure (BP), numerical rating scale pain scores up to POD2, and postoperative hospital length of stay. Forty-four patients in the T group and 45 patients in the M group were analyzed. The total dose of remifentanil infusion was significantly higher in the T group (T group: 0.093 (0.078-0.112) μg/kg/min; M group: 0.062 (0.052-0.076) µg/kg/min, p < 0.001). Within POD2, the overall PONV was not significantly different (27 (61.4%) vs. 27 (60.0%), p = 0.895). The HR (82 ± 11.5/min vs. 87 ± 11.1/min, p = 0.046) and mean BP (83 ± 17.2 mmHg vs. 90 ± 16.7 mmHg, p = 0.035) were significantly lower in the T group after tracheal intubation. The other postoperative outcomes were comparable between the two groups. Although the total remifentanil infusion dose was higher in the T group than in the M group, the postoperative outcomes were similar. If stable vital signs are desired during tracheal intubation, remifentanil infusion with TCI should be considered.

The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals’ Perspective: A Qualitative Study

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client's parents; 2. The key to treatment success: (a) Clients' awareness of the illness and (b) parents' support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

Effectiveness of Nesting and Swaddling Technique on Bio-physiological Parameters, Neuro-behavioral Activity and Sucking Response among Sick Neonates

Babies delivered before 37 weeks or 259 days of gestation are deemed premature. It is believed to be the direct cause of 24% of infant fatalities. While preterm births account for between 5% and 7% of all live births in some developed nations, it is believed that the proportion is much higher in developing nations. Nearly 30% of infants in India, or 7.5 million, are born low birth weight (LBW) (2500 g). This accounts for 42% of the global burden, more than any other nation. Approximately 60% of LBW neonates are born at term after fetal growth restriction, while the remaining 40% are born prematurely. The prevalence of SGA is 46.9%, exceeding all countries except two. Nesting is one of the most important factors in maintaining a healthy position for a premature infant, which involves positioning the hands near the face and the feet together while using positioning aids to create a secure, snug, and supportive nest. The capacity to nest keeps premature neonates in a comfortable position, enables spontaneous motor activity for skeletal joint and neuromuscular function, and facilitates the monitoring of stable vital signs. Commonly, infants are wrapped in a breathable, lightweight blanket to help them unwind and fall asleep.

Comparison of vital sign stability and cost effectiveness between midazolam and dexmedetomidine during third molar extraction under intravenous sedation

To compare the vital sign stability and cost of two commonly used sedatives, midazolam (MDZ) and dexmedetomidine (DEX). Patients and. This retrospective study targeted patients who underwent mandibular third molar extractions under intravenous sedation using MDZ or DEX. The predictor variable was the type of sedative used. The primary outcome variables were vital signs (heart rate and blood pressure), vital sign outliers, and cost of the sedatives. A vital sign outlier was defined as a 30% or more change in vital signs during sedation; the fewer changes, the higher the vital sign stability. The secondary outcome variables included the observer's assessment of alertness/sedation scale, level of amnesia, patient satisfaction, and bispectral index score. Covariates were sex, age, body mass index, sleeping time, dental anxiety score, and Pederson scale. Descriptive statistics were computed including propensity score matching (PSM). The P-value was set at 0.05. The study enrolled 185 patients, 103 in the MDZ group and 82 in the DEX group. Based on the data after PSM, the two samples had similar baseline covariates. The sedative effect of both agents was satisfactory. Heart rate outliers were more common with MDZ than with DEX (49.3% vs 22.7%, P=0.001). Heart rate was higher with MDZ (P=0.000). The cost was higher for DEX than for MDZ (29.27±0.00 USD vs 0.37±0.04 USD, P=0.000). DEX showed more vital sign stability, while MDZ was more economical. These results could be used as a reference to guide clinicians during sedative selection.

Penetrating Neck Injury due to Foreign Body at C5 Level with Plexus Brachialis Nerve Injury: A Case Report

Abstract: Penetrating neck injury caused by screwdriver is a very rare case. Rapid transport to a major trauma center is needed for such patients to prevent neurological dysfunction and post traumatic tissue damage. Early and complete assessment and exact surgical procedure are very important to overcome a good outcome and prognosis. We reported a case of a 28-year-old male transferred to the emergency room after being stabbed using a screwdriver. No history of nausea, vomiting, and loss of consciousness. A screwdriver got stucked on the neck at the level of C5-C6 associated with edema but no active bleeding. The upper extremity examination revealed that the muscle contraction was 5555/4444, thumb test +/, opposition test +/-, abductor adductor test +/-, and sensory within normal limit. Radiology examination showed a metallic density of the foreign body in the cervical region penetrating from soft tissue to the vertebral body of cervical C5. The patient was diagnosed with penetrating neck injury due to foreign body in the posterior neck region at C5 level with plexus brachialis nerve injury. Foreign body removal and laminectomy were done to decompression purpose. This case need early, complete and adequate management to prevent post traumatic tissue damage, other neurological dysfunction, and mortality. On the fourth post-surgical day, the patient was discharged with stable vital signs and no neurological deficit. The regular follow up at the neurosurgical clinic showed that neither motoric nor sensoric deficit was found. In conclusion, penetrating neck injury which can cause severe morbidity and permanent disability need an adequate management to prevent any spinal cord damage and minimize any neurological dysfunction. Keywords: penetrating neck injury; spinal cord injury

23 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) EXPLOSION AFTER GUNSHOT: WHEN DEVICE PROTECTS TWICE

Abstract A 70 years old man presented to the emergency department with “accidental” gunshot wound at left hemithorax and left shoulder/arm. Initial clinical assessment showed stable vital signs and implantable cardioverter defibrillator(ICD) protruding outside from large wound in the infraclavicular region. The ICD, previously implanted for secondary prevention of ventricular tachycardia, appeared burned and the battery was exploded. Urgent chest computed tomography scan was performed with evidence of left omeral displaced fracture, large hematoma without arterial injury and many shotgun pellets in left shoulder/arm. The ICD generator was disconnected from passive fixation leads and removed. Patient was stabilized and omeral fracture was fixed. Following leads extraction was successfully performed in hybrid operating room with cardiac surgery standby considering the difficulty of the procedure, the type of leads (double coil, passive fixation) and the risk of complications. The patient was discharged home in good clinical conditions after re-implantation of novel ICD in right infraclavicular region. Emerging technologies are promising in making lead extractions safer and more accessible for patients worldwide. This clinicl case report will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this field.

Outcomes in ED patients with non-specific ECG findings and low high-sensitivity troponin.

Although some emergency department risk stratification tools consider non-specific ECG findings as an aid in disposition decisions, their clinical value in patients with an initially low high-sensitivity cardiac troponin I (hsTnI) is unclear. Our purpose was to determine if non-specific ECG (ns-ECG) findings are associated with 30-day major adverse cardiac events (MACE) in ED patients presenting with suspected acute coronary syndromes (ACS) who have a low initial hsTnI. Using the prospective Siemens Atellica hsTnI Food and Drug Administration submission observational database, we conducted a retrospective cohort study of the association between ns-ECG findings (defined as left bundle branch block [LBBB], ST depression [STD], or T-wave inversions [TWI]) and 30-day MACE (death, myocardial infarction, heart failure hospitalization, or coronary revascularization). Eligible patients presented with suspected ACS to one of 29 US EDs from April 2015 to April 2016, had stable vital signs, a blood sample for hsTnI (Siemen's Atellica, Siemens Healthineers, Inc, Malvern, PA) obtained at 1, 3, and 6hours after ED presentation, and were followed for 30 days. The relationship between 30-day outcome, initial hsTnI, and ns-ECG was evaluated using chi-square testing. Of 2676 enrolled, 1313 patients met the inclusion criteria and are included in the analysis. Median (interquartile range) age was 62 years (54, 72), 54% were male, with 56% white, and 39% African American. Median (interquartile range) times from symptom onset to presentation and presentation to specimen collection were 92 (0, 216) and 146 (117, 177) minutes, respectively. The most common presenting symptoms were chest pain (84%), followed by dyspnea (9%). ECG findings were categorized as T-wave inversion or non-specific T wave changes (42%), ST depression ns-ECG ST changes (16%), or LBBB (2%). Thirty-day MACE occurred in 72 (5.5%) patients, with coronary revascularization (35 patients, 2.7%) and heart failure (25 patients, 1.9%) being the most frequent outcomes. In patients with an initial hsTnI below the limit of quantitation (LOQ) of 2.5ng/L (n=449), there was no association between ns-ECG changes and 30-day MACE (P=0.42). If the hsTnI was ≥LOQ (2.5ng/L), there were increased rates of 30-day MACE and ns-ECG findings (P=0.01). In ED suspected ACS patients without unstable vital signs, and an initial hsTnI less than the LOQ (2.5ng/L), ns-ECG findings are not associated with 30-day major adverse cardiac events. The use of ns-ECG findings in ACS disposition should be considered in the context of hsTnI levels.

Woman With Progressive Abdominal Pain

A 65-year-old woman presented to the emergency department with a 2-day history of intermittent but aggravating lower abdominal pain with nausea. She denied having a fever or vomiting. She had previously undergone surgeries for appendicitis, ectopic pregnancy, and vaginal prolapse. She was lucid and had stable vital signs. Physical examination revealed diffuse lower abdominal pain with peritoneal signs and decreased bowel sounds. Pelvic ultrasonography indicated thickening of the small bowel (Figure 1).

A Very Rare Case of Severe Anemia Caused By Vitamin B 12 and Folate Deficiency with Non-Immune Intramedullary Hemolysis

Introduction: Macrocytic anemia can be associated with chronic alcohol use, vitamin B12 and folic acid deficiency. However, it is very uncommon to see severe anemia in developed world, especially in a young healthy patient without any medical issues. Folate deficiency is rarely reported to cause hemolytic anemia. We present an interesting case report of a young female with severe anemia from vitamin B12, folate deficiency and nonimmune intramedullary hemolysis. Case: 40-year-old Caucasian female with no significant past medical history, who has not seen a doctor in the last 20 years presented to our emergency department complaining of worsening shortness of breath and bilateral lower limb swelling for the last 6 months prior to admission. Shortness of breath had been worsening in the last 2 months to a point that she can barely walk about 6 feet. Patient also reported non-bloody diarrhea for the last few weeks, reports looking pale by her coworkers. She is a nonsmoker, drinks about 2 drinks a day, no illicit drug use and works as a state trooper police officer. Patient had stable vital signs with tachycardia of heart rates in 90s, physical exam showed scleral icterus and pallor and 2 + bilateral lower limb pitting edema. Blood work showed hemoglobin 2.2 mg/dl, hematocrit 6.9, MCV 153.3, MCH 48.9, MCHC 31.9, platelet count 62, reticulocyte 2.1%, low vitamin B12 of 159pg/ml, low serum folate, elevated LDH and low haptoglobin. Negative direct combs test, Negative Celiac antibodies, normal iron panel, negative HIV, hepatitis A, B and C serologies, EBV, normal methylmalonic acid level, elevated homocysteine level, negative PNH panel. Patient had a normal EGD and colonoscopy, and negative stool studies including C.diff, shigella, salmonella, vibrio, and E.coli. Patient received 5 units of packed red blood cells and 1 unit of FFP. Hemoglobin improved with 5 units packed red blood cells, IV folic acid and IM vitamin B12 injections. Patient was discharged home on oral folic acid and vitamin B 12 replacement. Conclusion: Severe anemia from isolated folate and vitamin B 12 although uncommon in young healthy patients but should be considered in the differential diagnosis. Intramedullary hemolysis is a rare presentation of severe folate deficiency with limited literature. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Effect of combined application of sevoflurane and remifentanil on laparoscopic surgery, postoperative recovery time and stress response

Purpose: To investigate the effect of application of sevoflurane and remifentanil on laparoscopic surgery, and its effect on patients’ postoperative recovery time and stress response. &#x0D; Methods: Ninety patients undergoing laparoscopic surgery in Zhongshan City People's Hospital, Guangdong Province, China were selected and randomly divided into propofol group (PG) and sevoflurane group (SG), with 45 patients in each group. Patients in PG were anesthetized with combination of propofol and remifentanil, while those in SG received combination of sevoflurane and remifentanil. Patients’ heart rate (HR), stroke volume (SV) and mean arterial pressure (MAP) were tested before anesthesia induction (T1), after intubation (T2), 15 min after pneumoperitoneum (T3), and after extubation (T4), in order to evaluate the stability of vital signs in the patients. &#x0D; Results: At T2, T3, and T4, HR, SV, and MAP were more stable in SG than in PG (p &lt; 0.05). At T3 and T4, the levels of ET-1, noradrenaline (NE) and cortisol (Cor) were significantly lower in SG than in PG (p &lt; 0.05). Furthermore, postoperative recovery time, spontaneous breathing time, time taken to open the eyes under command, and orientation recovery time were shorter in SG than in PG (p &lt; 0.05). After awakening, SG had significantly higher Ramsay score than PG (p &lt; 0.05). &#x0D; Conclusion: The combined use of sevoflurane and remifentanil for anesthesia in patients undergoing laparoscopic surgery results in stable vital signs, facilitates recovery after surgery, improve quality of recovery, and reduce stress response. Therefore, the combination anesthesia merits further mechanistic and large-scale investigation before clinical application.

Removal of a pellet from the left ventricle trabeculae: A case report

Cardiac gunshot wounds, despite being rare, have a high mortality rate, and their proper management and prompt decision-making are critical.Here we present a case of cardiac gunshot woundin a young male who was shot at close range in the left shoulder from behind. The patient admitted at hospital with stable vital signs, but after a while, shortness of breath was begun and pneumothorax was diagnosed. Due to the instability of the pellet which localized in the LV using echocardiography, surgical excision of the pellet was planned. Patient was discharged two week the pellet removal with no complications.

PSAT327 Can Cannabis Use Lead to Central Hypothyroidism

Abstract Background Marijuana has been legalized for medical use in 36 states and for recreational use in 18 states. Its effects on thyroid function and hypothalamic-pituitary-thyroid axis in humans is not known. Clinical Case 72 years old male presented to his primary care physician with occasional difficulty swallowing. He reported fatigue for 4-5 years, trouble falling asleep for 2 months, weight gain 8 pounds over last few weeks, occasional diarrhea, and intermittent episodes of heat intolerance. His past medical history included controlled type 2 diabetes mellitus, recurrent herpes simplex infection, arthritis of hip joints, short-term memory loss, anemia, carpal tunnel syndrome and benign prostatic hyperplasia. Medications included glimepiride, lisinopril, acyclovir, tamsulosin, finasteride, escitalopram. He had been smoking marijuana regularly since he was a teenager. He denied using any other supplements. His physical exam was normal with stable vital signs and normal BMI. His labs showed a low TSH (0.096 mcIU/mL, n: 0.358-3.8 mcIU/mL), normal free T4 (0.90 ng/dL, n: 0.76-1.46 ng/dL), normal total T3 (70 ng/dL, n: 60-180 ng/dL). Review of his labs showed low TSH for last 4 years progressively getting worse with normal free T4 levels. TSH-receptor antibody and TPO Antibody level were negative. His white cell count, hemoglobin and platelets were normal. His electrolytes, kidney function and liver function tests were also normal. Thyroid Ultrasound showed 2 small sub-centimeter hypoechoic nodules in the left thyroid lobe. Two years ago, a radioactive Iodine scan showed normal iodine uptake. A recent radioactive iodine uptake scan showed generalized decreased iodine uptake with no evidence of graves’ disease or toxic multinodular goiter. Conclusion Currently there are no controlled studies on the effect of marijuana use on thyroid function in humans. A cross-sectional analysis using National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012 showed recent marijuana use was significantly associated with lower levels of TSH but was not associated with thyroid dysfunction (1). This study suggests that marijuana use is associated with low TSH levels. This could be due to hypothalamic suppression of TSH or may indicate a protective role against hypothyroidism. Older studies in rodents showed that cannabis exposure may lead to suppression of TSH and hypothalamic function (2). The data related to human subjects is scarce. Therefore, pathophysiologic mechanisms are speculative, although animal data support potential mechanism of hypothalamic suppression.

ODP318 Idiopathic Granulomatous Hypophysitis : A Rare Cause of Hypopituitarism

Abstract Introduction Pituitary hypophysitis is an inflammatory disorder classified as primary or secondary. The five histologic subtypes of primary hypophysitis are lymphocytic, granulomatous, xanthomatous, IgG4-related, and necrotizing. Idiopathic granulomatous hypophysitis (IGH) has an incidence of 1 in 10 million and accounts for &amp;lt; 1% of cases involving panhypopituitarism, headache, and visual disturbances. We present the case of IGH in a patient initially suspected to have pituitary adenoma. Case Presentation A 54-year-old female with a history of hypertension presented to the emergency department with nausea, vomiting, and acute worsening of a chronic headache of 1-week duration. Her past medical history was significant for a suspected pituitary macroadenoma of 1.7 cm, which was incidentally detected 7 months before the current presentation. She reported a history of 9 lb weight gain in one month, hot flashes, and diplopia, but denied hirsutism, polyuria, polydipsia, and galactorrhea. Prior evaluation revealed normal prolactin, TSH, and visual field testing. Her medication and familial history were unremarkable. Physical exam during the current presentation revealed stable vital signs, left eye exophthalmos, left anisocoria, decreased sensation in the left V1 and V2 trigeminal nerve distribution, and right abducens nerve palsy. Her initial laboratory workup was consistent with panhypopituitarism. Brain Magnetic Resonance Imaging (MRI) revealed an extensive, locally invasive, exuberantly enhancing infiltrative process measuring at least 5.6 cm in maximal transverse diameter involving the pituitary gland with bilateral cavernous sinus and Meckel's caves invasion and extension into bilateral superior orbital fissures. The patient underwent supraorbital craniotomy with subtotal resection of the tumor. Tuberculosis, sarcoidosis, and neoplasm were ruled out by appropriate tests, and the patient was diagnosed to have IGH on histology. Her symptoms improved postoperatively and the patient was discharged on levothyroxine and hydrocortisone. Conclusion Clinically and radiologically, IGH is a rare pathology that can closely mimic a pituitary adenoma. Through this case, we highlight the importance of performing a comprehensive evaluation with a full hormonal workup and imaging, with the exclusion of secondary causes while assessing patients with a sellar mass. Presentation: No date and time listed

PMON99 A Rare Case of an Intrasellar Epidermoid Cyst And Panhypopituitarism

Abstract Introduction Epidermoid cysts are rare intracranially occurring mainly in subarachnoid spaces such as parasellar cisterns, middle fossa and cerebellopontine angle. Only few cases of infundibular/sellar epidermoid cysts have been described. We present the case of a large sellar epidermoid cyst resulting in panhypopituitarism. Case 49 year old male with history of obesity and hypertension presented to the emergency department with acute onset progressively worsening headaches. He denied vision changes, nausea, vomiting or dizziness. Examination showed stable vital signs and ophthalmologic exam did not reveal any visual deficits. Further, he did not have any signs of pituitary hormone excess including hypercortisolemia or acromegaly. Brain MRI with and without IV contrast revealed a peripherally enhancing multilobulated cystic pituitary mass measuring 19.5 mm×17 mm×20.5 mm deviating the infundibulum to the left causing compression of the caudal aspect of the optic chiasm. Initial endocrinology work-up revealed noon time cortisol of 10.7 mcg/dL (range 7-23), 7 pm ACTH of 34.6 pg/mL (range 7.2-63.3), TSH of 1.71 mIU/mL (range 0.35- 4.94), free T4 of 0.93 ng/dL (range 0.5-1.39), FSH of 4.45 mIU/mL (range 1.27-19.26), LH 5.51 mIU/mL (range 1.24-8.62), IGF-1 level of 199 ng/mL (range 68-225), prolactin &amp;lt;0.60 ng/mL (range 2.64-13.13), and testosterone level of 186 ng/dL (range 175-800). A presumed diagnosis of non- functioning pituitary macroadenoma with compression of chiasm was made and he underwent transsphenoidal hypophysectomy after evaluation by a multi-disciplinary team including neurosurgery, ENT and endocrinology. Post-operative course was uneventful, he was started on empiric steroids which were tapered slowly. Final pathology of surgical specimen demonstrated epidermoid cyst, focal necrosis, lymphocytes and macrophages infiltration consistent with reactive granulation tissue. On subsequent laboratory evaluation, he was found to have hypogonadotropic hypogonadism with an undetectable testosterone. FT4 was also low at 0.61 ng/dL (range 0.5-1.39). He is closely following with endocrinology for management of hypogonadotropic hypogonadism and hypothyroidism. Conclusion Intracranial epidermoid cysts are uncommon benign congenital lesions arising from trapped surface of ectodermal elements. Very rarely, they are found in the sellar region. Sellar epidermoid cysts tend to present late and often after significant growth and mass effects. Complete resection is challenging and recurrence is a feared complication. Our patient presented with acute symptoms from expansion of a large epidermoid sellar cyst mimicking a pituitary macroadenoma. It also resulted in hypopituitarism. Although, a rare entity, early recognition and prompt management of such lesions is key. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Safety of same-day discharge after peroral endoscopic myotomy.

There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

SERRATIA LIQUEFACIENS SEPTICEMIA SECONDARY TO CONTAMINATED MULTIVITAMINS

SERRATIA LIQUEFACIENS SEPTICEMIA SECONDARY TO CONTAMINATED MULTIVITAMINS

S3261 A Case of Rheumatoid Nodules in the Liver

Introduction: Rheumatoid arthritis (RA) has a prevalence of 0.5-1%. Extra-articular manifestations, including rheumatoid nodules (RNs), can be present in up to 40% of individuals. Rarely, RNs can manifest in the gastrointestinal system. We present a case of a 52-year old female with RA who presented with hepatic nodules and fever. Case Description/Methods: A 52-year-old woman with seronegative RA on sulfasalazine 1000mg BID presented with three weeks of fevers ranging from 101 – 103 F. She had been on adalimumab until one year ago, which was stopped after she developed a psoriatic rash. Six months ago she diagnosed with an incidental left upper lobe pulmonary nodule but IR biopsy was non-diagnostic. On admission, the patient was afebrile with stable vital signs, and the following labs: WBC 25, CRP 6.44, ESR 70, and ALP 179, with normal ALT, AST, and bilirubin. A chest, abdomen and pelvis contrast CT scan showed reduced size of the previous lung nodule but multiple new hypodensities within the liver, with the largest lesion 2cm in diameter (Figure 1a). Liver MRI confirmed numerous hepatic lesions (Figure 1b). After admission, she remained afebrile and her WBC resolved without antibiotics. Infectious, malignancy, and autoimmune workup were negative. The patient underwent a colonoscopy with no concerning signs for malignancy. She then underwent an IR liver biopsy and pathology revealed multiple necrotizing granulomas with plasma cells, most concerning for RNs. Rheumatology and hepatology were consulted and planned to increase her sulfasalazine and get repeat abdominal imaging at her next visit. Discussion: Although extra-articular disease is evident in RA, RNs in the liver are rare. A postmortem analysis of a patient from 1986 identified multiple nodules up to 5mm. In 2019, a 62 year-old female had abdominal pain and was found to have a 5cm RN in the liver. A 61 year-old male in 2020 had a 4cm liver mass resected with histology revealing a necrotizing granulomatous inflammation suggestive of a RN. Additionally, prior studies have shown that cells in RNs produce similar proinflammatory cytokines as those in synovial membranes. This could suggest cytokine release due to RNs as a cause of our patient's fevers. Although she had well controlled RA, she was also previously treated with TNF inhibitors which have been noted to cause RNs in the lungs. This may have led to her pulmonary and hepatic nodules. Overall, our case adds to the data highlighting uncommon gastrointestinal manifestations of RA.Figure 1.: Figures 1a and 1b. CT and MRI Studies Revealing Multiple Hepatic Hypodensities.

PRIMARY SPONTANEOUS PNEUMOTHORAX WITH AN APICAL BLEB: CONTROVERSIES IN WORKUP AND MANAGEMENT

A 16-year-old boy presented to the pediatric emergency department (ED) for evaluation of chest pain. Two days prior to arrival to the ED, he woke up with chest pain, cough, and shortness of breath. He attributed it to allergies and asthma, and used his albuterol inhaler. He described pain localized in his left chest that worsened with deep inspiration. He also felt lightheaded when taking a deep breath. He reported infrequent marijuana use and vaping. On presentation, the patient had stable vital signs with heart rate of 64 beats/min, respiratory rate of 18 breaths/min, and pulse oximetry of 100% on room air.

S3119 Patient With Autoimmune Hepatitis Requiring Liver Transplant: Case Report and Literature Review

Introduction: Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease caused by autoimmune-induced damage to the hepatocytes. AIH is known for elevated anti-smooth muscle antibodies (ASMA) and serum globulin levels. A liver biopsy is needed for the diagnosis. Despite its favorable prognosis, few cases can progress to fulminant liver failure. Case Description/Methods: 71-year-old male maintained on Descovy as preexposure prophylaxis for HIV for 1 year, was admitted 3 consecutive times over 1 month due to fatigue and jaundice. He was noted to have elevated transaminase and bilirubin levels. His presentation was suspected to be secondary to Descovy. Abdominal ultrasound was notable for hepatomegaly otherwise normal. He reported social alcohol consumption. He denied acetaminophen or new medication use. PE showed stable vital signs with jaundiced skin and hepatomegaly. The laboratory workup is shown below. Descovy was stopped and he was discharged. He was readmitted 1 week later for worsening symptoms. Workup showed positive ASMA for which he underwent a liver biopsy which was consistent with AIH. Infectious workup was unremarkable. He was started on a prednisone taper. Liver enzymes stabilized and he was discharged with plans to start azathioprine as an outpatient. However, he was admitted 2 weeks later for abdominal pain and encephalopathy. His labs showed worsening bilirubin, INR, and creatinine levels. CT head and abdomen were unremarkable. Doppler ultrasound demonstrated patent hepatic vasculature. He was placed on IV hydration, lactulose, and rifaximin. Due to concerns for hepato-renal syndrome, midodrine, octreotide, and albumin were added. He had a liver transplant evaluation which he underwent successfully. After prolonged hospitalization, he was discharged to post-acute rehab with a regimen consisting of tacrolimus, azathioprine, and prednisone (Figure 1). Discussion: The initial treatment for AIH is glucocorticoid therapy. Azathioprine can be added in moderate to severe cases or when there is a contraindication from using high-dose steroids. Few studies showed that tacrolimus can be effective in some cases that do not respond to steroids. Response to treatment is assessed by improvement of symptoms, laboratory tests, and liver histology. A liver transplant remains a rare indication in AIH and is reserved for patients who do not respond to immunosuppressants or progress to fulminant liver failure. The recurrence rate is reported to be 20-40% with a possibility of developing de novo AIH in a few cases.Figure 1.: Image A is showing portal tract with reactive bile ducts, abundant plasma cells, and interface hepatitis (H&E stain, 10×). Image B is showing Lobular aggregate of plasma cells adjacent to a central vein and involving hepatocytes which show reactive changes including ballooning (H&E stain, 20×). Table 1. - Test Admission #1 Admission #2 Admission #3 Post-transplant Reference range AST 481 952 264 32 5-45 U/L ALT 1048 1284 501 61 12-78 U/L ALP 236 184 166 66 46-116 U/L Total bilirubin 15.29 36.00 42.02 0.68 46-116 U/L Direct bilirubin 11.47 26.99 30.82 0.24 0.00 - 0.20 mg/dL Total protein 7.5 7.2 6 7 6.4-8.2 g/dL Albumin 3.3 2.7 2.1 3.7 3.5-5.0 g/dL PT 14.5 17.9 44 13.5 11.5-14.5 seconds INR 1.13 1.49 5.04 1.07 0.84-1.19 BUN 20 19 107 39 5-25 mg/dL Creatinine 1.28 1.39 4.03 4.37 0.6-1.3 mg/dL eGFR 56 51 13 12 ml/min/1.73sq.m Hemoglobin 17 16.5 16.7 11.3 12.0-17.0 g/dL WBC 7.89 8.74 16.2 6.13 4.31-10.16 thousands/uL Platelets 125 118 165 165 149-390 thousands/uL Sodium 134 132 131 139 136-145 mmol/L Potassium 3.7 3.7 5.3 4.4 3.5-5.3 mmol/L Chloride 100 100 103 103 100-108 mmol/L Calcium 8.9 9.2 9.2 10.1 8.3-10.1 mmol/L Ammonia 31 24 53 N/A 11 - 35 umol/L ASMA 40 0-19 U AMA < 20 0-20 U ANA Negative Negative IMMUNOGLOBULIN AIMMUNOGLOBULIN G IMMUNOGLOBULIN M 101112393 50-500 mg/dL650-2000 mg/dL40-270 mg/dL Acetaminophen < 2 10-20 ug/ml Urine drug screen Negative Negative Ceruloplasmin 22.2 16-31 mg/dL A1 antitrypsin 131 90-200 mg/dL Viral hepatitis panel Negative Negative HIV 1/2 AB-AG Negative Negative AST: Aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase; INR: international normalized ratio; PT: prothrombin time; BUN: blood urea nitrogen; eGFR: estimated glomerular filtration rate; WBC: white blood count; ASMA: Anti-smooth muscle antibody; AMA: anti-mitochondrial antibody; ANA: antinuclear antibody.