Stable Vital Signs Research Articles

The use of routine laboratory testing in acute trauma care: A retrospective analysis.

In more than 60 countries worldwide, laboratory testing plays a challenging and expensive role in trauma resus-citation. In 1995, the literature already suggested that routine laboratory testing may not be useful for most trauma patients. Our study hypothesized that still the need for some laboratory tests perhaps should be reconsidered. Therefore, the aim of this study was to create more insight in the distribution between normal and abnormal parameters for routine laboratory testing in trauma patient management. This retrospective analysis was performed at Amsterdam UMC, location AMC, an academic level 1 trauma center. Data concerning age, gender, American Society of Anesthesiologists (ASA) physical state classification system (ASA), Injury Severity Scores, Glasgow Coma Scales, mechanism of injury, presence of high-energy trauma, and type of injury (blunt or penetrating) were obtained. Laboratory parameters included comprehensive hematology, coagulation, arterial blood gas, kidney, and liver blood panels. Analytical focus was paid to the patient's vital status, the indication for an emergency intervention, and the risk of in-hospital mortality. A total of 1287 patients were included in the study. Patients with unstable vital signs or who required emergency inter-vention were most often dealing with abnormalities in pO2, glucose, D-dimer, creatinine, and alcohol values. Mean corpuscular volume (MCV), international normalized ratio (INR), fibrinogen, and amylase were obtained in more than 80% of the patients, but in specific patient groups only abnormal in less than 9%. Trauma patients suffer mainly from abnormal values of D-dimer, pO2, glucose, creatinine, and alcohol. By contrast, MCV, INR, amylase, fibrinogen, and thrombocytes are regularly obtained as well, but only abnormal in a small amount of trauma patients. These findings suggest reconsiderations and more accuracy in the performance of laboratory testing, especially for trauma patients with stable vital signs.

Bleeding complication after surgical removal of impacted teeth in a patient with undiagnosed clotting disorder

ABSTRACT To report one case of bleeding episodes after impacted teeth extractions had been performed in a patient with undiagnosed clotting disorder, describing a sequence of approaches for hemostasis up to the appropriated diagnosis and effective resolution. A male 16-year old patient with surgical indication to remove eight impacted teeth. After the surgery, there were bleeding episodes, being needed for hospital admission to keep on his physiological functions, blood pressure and heartbeat frequency regularly, to carry out laboratory blood tests, and to achieve hemostasis by using antifibrinolytics and blood products. After 24 hours, 11% of IX clotting factor was verified into bloodstream by specific blood test, being diagnosed with mild Hemophilia B. From the diagnosis, infusions of IX clotting factor were performed to the adequate resolution and recovery of the patient. The clinical conducts were efficient to keep on stable vital signs and achieving appropriate diagnosis. However, preventive behaviors should be applied in hemophilic patients in pre- or intra-operative, avoiding circumstances that can compromise health condition of the patient.

The Effective Role of Adding Letrozole to Methotrexate in the Management of Tubal Ectopic Pregnancies, a Randomized Clinical Trial.

Ectopic pregnancy (EP) is considered a main reproductive health challenge. According to the side effects of using methotrexate (MTX), it is rational to find safer drugs in the management of EP. This randomized controlled trial aimed to evaluate the efficacy and safety of adding letrozole to the single-dose MTX in the management of EPs. This study was conducted in an academic hospital affiliated to Tehran University of Medical Sciences. Women with EP and stable vital signs with β-hCG levels ≤3500 were assigned randomly to receive MTX + placebo or MTX + letrozole. The regression pattern of β-hCG, need for further surgery, and potential side effects were compared between groups. A total of 90 women were assigned equally to the study groups and were matched in age, body mass index (BMI), serum biochemistry, and primary levels of β-hCG. No drug-related side effects were observed in groups. The rates of further surgery (p = 0.614) and second dose of MTX (p = 0.809) were not significant between groups. In the MTX + placebo group, we observed a minor increase in β-hCG levels on day 4 followed by a decreasing pattern on days 7 and 14. But, in MTX + letrozole group, a decreasing pattern in β-hCG levels from day 1 through day 14 was perceived. The results support using MTX + letrozole to treat stable women diagnosed with tubal EP as a safe and efficient method. Further studies are required to evaluate letrozole alone as an alternative therapy in EPs.

An Audit of Surgical Neck Explorations for Penetrating Neck Injuries in Northwestern Nigeria: Experience from a Teaching Hospital.

Background:Penetrating neck injury is a major trauma mechanism present in about 5%–10% of trauma patients with an estimated mortality of 3%–10%. The management of these injuries is dependent on the anatomical level of injury.Objectives:The objective of the study was to document the clinical and operative findings as well as the treatment outcome among our patients who underwent neck exploration for penetrating neck injuries.Materials and Methods:A retrospective review of patients who had neck exploration for penetrating neck injury between January 2012 and December 2018 was done.Results:Thirty-five patients all of whom had surgical neck exploration were included. The age ranged from 15 to 62 years with a male: female of 7.8:1. The mean age was 30.7 years with standard deviation of ± 12.5 years and the peak age of occurrence of 20–29 years. The mechanism of injury was commonly arrow injury in 9 (25.7%) and suicidal cutthroat in 7 (20%) patients. Thirty-two (91.4%) patients presented with stable vital signs. Zone II neck injuries were most prevalent, seen in 23 (65.7%) patients. Laryngeal injury in 7 (20%) and soft-tissue injury in 7 (20%) of the patients were the most common intraoperative findings. The complication rate of 17.1% with a mortality rate of 2.9% was recorded. There was a statistically significant association between the presence of vascular injury and the development of complications after exploration (Chi-square = 5.666, P = 0.017). It was also a significant positive predictor of complication following neck exploration (odds ratio = 0.017, P = 0.048).Conclusion:Male young adults were most involved, commonly from arrow and stab injuries. Although laryngeal and soft-tissue injuries were predominant, vascular injuries were most associated with postoperative complications.

Decision Making Based on Clinicoanatomic Criteria to Select Open Versus Endovascular Repair for In nominate Artery Pseudoaneurysms Management

Background: The quality of present data on the effectiveness of endovascular repair (EVR) or open surgery (OS) to treat in nominate artery pseudoaneurysms (IAPs) is poor. The use of EV might simplify the procedure and provide a meaningful alternative for this condition, but it remains to be proved. We analyzed all IAP cases handled by OS or EVR from the literature to affect the decision-making for OS or EVR, basing the choice of intervention on clinicoanatomical data analysis. Methods and results: All relevant literature reports of EVR and OS management of IAP were analyzed comparatively. Evidence-based data were extracted from the literature using Medline and Embase database resources. We totally recorded 73 cases, 50 from OS repair and 23 received EVR. Most patients who displayed hard signs or stable vital signs have been significantly managed by OS (94% vs. 57%) or EVR (43%vs. 8%) respectively. There was a significant predominance of iatrogenic injuries in the EVR group compared with those handled by OS (39%vs. 26%) except for patients who underwent endovascular stenting. OS was performed in the large majority of patients with severe blunt traumas (50%vs. 22%)(p=0.0328). Many patients classified as having cardiothoracic comorbidities benefited from EVR therapy (52%vs. 20%). Some cases in which arterial wounds were limited to the mid segment of the IA underwent EVR with significant proportion compared to the OS group (26%vs. 24%) (p=0.004). Patients in the EVR group had more operative failure and complications rates (39%) rather than those in the OS group (20%) (p< 0.05). Of the 23 patients managed by EVR, two had premature mortality (8.7%); of the remaining cases that received OS, the early mortality rate represented 6%. The significant causes for OS-related morbimortality were multiple organ failures, acute right heart insufficiency, pneumonia, deep vein thrombosis and hemorrhagic shock. Overall events for EVR-related death included stroke complications and massive hemorrhage from endoleak. The mid-term follow-up rate was significantly higher for the EVR group (57%) compared to the OS group (30%). Conclusion: Compared with OS repair, EVR might represent an attractive alternative strategy for managing IAPs. The most primary option for OS included unstable patients, suffered from endovascular stenting, free of comorbidities and when the arterial wound is located at the distal portion of the IA.

Part 4. Clinical Practice Guideline for Surveillance and Imaging Studies of Trauma Patients in the Trauma Bay from the Korean Society of Traumatology

The following recommendations are presented herein: All trauma patients admitted to the resuscitation room should be constantly (or periodically) monitored for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation, body temperature, electrocardiography, Glasgow Coma Scale, and pupil ref lex (1C). Chest AP and pelvic AP should be performed as the standard initial trauma series for severe trauma patients (1B). In patients with severe hemodynamically unstable trauma, it is recommended to perform extended focused assessment with sonography for trauma (eFAST) as an initial examination (1B). In hemodynamically stable trauma patients, eFAST can be considered as the initial examination (2B). For the diagnosis of suspected head trauma patients, brain computed tomography (CT) should be performed as an initial examination (1B). Cervical spine CT should be performed as an initial imaging test for patients with suspected cervical spine injury (1C). It is not necessary to perform chest CT as an initial examination in all patients with suspected chest injury, but in cases of suspected vascular injury in patients with thoracic or high-energy damage due to the mechanism of injury, chest CT can be considered for patients in a hemodynamically stable condition (2B). CT of the abdomen is recommended for patients suspected of abdominal trauma with stable vital signs (1B). CT of the abdomen should be considered for suspected pelvic trauma patients with stable vital signs (2B). Whole-body CT can be considered in patients with suspicion of severe trauma with stable vital signs (2B). Magnetic resonance imaging can be considered in hemodynamically stable trauma patients with suspected spinal cord injuries (2B).

A Case of Dimethoate Poisoning Requiring Prolonged Skin Decontamination

Background Decontamination is a critical medical counter measure in reducing toxic exposure following poisoning. Little is known on the effectiveness of this procedure and its impact in the context of preventing secondary exposure of healthcare workers and secondary contamination of facilities. Presented here is a case of dimethoate poisoning that required a prolonged period of skin decontamination to remove residual skin contamination. Case Report A young gardener consumed dimethoate at the workplace witnessed by a colleague who called the emergency services immediately. Paramedics noted the patient to be drowsy with stable vital signs and 100% oxygen saturation. En-route to the hospital the patient vomited multiple times and was drenched in vomitus with a pungent odour. Upon arrival at the emergency department (ED), vital signs remained stable with a Glasgow Coma Scale (GCS) of 10. Due to gross external contamination from the vomitus and pungent odours emanating suggestive of chemical fumes off-gassing, the hospital decontamination shower was activated for patient decontamination. Staff donned protective suits and proceeded to disrobe and bag all the patient’s clothing before showering the patient for 10-minutes using soap and water. Post-decontamination a chemical agent monitor (CAM) were used to screen for residual chemicals following the hospital’s decontamination protocol. The chemical alarm was triggered twice, first around the left mastoid region and again just below the left breast. This required targeted re-showering for a further 10-minutes before patient was finally cleared of contamination. Subsequently, the patient was given atropine (2.4 mg) and pralidoxime (1 g) followed by an infusion at the intensive care unit (ICU). The patient made an uneventful recovery and was discharged 5-days later. Conclusion This case of dimethoate poisoning is notable for the prolonged period of skin decontamination to remove residual skin contamination and illustrates potential implications to patient and health care worker safety. Past mass casualty incidents involving chemicals, such as the sarin attack in Tokyo, highlight the high incidence of secondary exposures amongst healthcare workers due to the lack of casualty decontamination. As a result, many hospitals have developed capacity to conduct rapid and timely decontamination at their premises to prevent further complications from secondary chemical exposure. However, the effectiveness of this process of decontamination needs further evaluation.

A diagnostic challenge presented in a 37-year-old man with severe weight loss and

[1] A 37-year-old man, Iranian resident in Zanjan, presented to the gastroenterology clinic of Taleghani Hospital; a teaching referral hospital in Tehran, Iran, with chief complaint of a significant weight loss about 20 kg in recent 4 months. He denied any concomitant systemic signs and symptoms except for a generalized malaise. He did not mention any change in bowel habit and eating pattern but a slight decrease in appetite without nausea and vomiting. He denied smoking and use of any illicit drug or alcohol. His past medical history was negative. He was admitted for further work regarding his unexplained weight loss. On admission, he was well with stable vital signs. His blood pressure was 110/70 mmHg, body temperature: 36.5 o C, heart rate: 84 bites per minute, and respiratory rate: 13 per minute all within normal limits. His physical exam was only notable for a mild epigastric and right upper quadrant (RUQ) tenderness. His laboratory tests were normal except for a normochromic normocytic anemia with a hemoglobin concentration of 12 mg/dl. Serum iron level was 37 mcg/dl with a total iron binding capacity (TIBC) level of 275 mcg/dl and a ferritin level of 10 mcg/l revealing an iron deficient erythropoiesis. Further laboratory tests evaluating tumor markers, thyroid function tests, liver function tests, serum bilirubin level, urine analysis and stool examination were all normal. We decided to proceed with an upper gastrointestinal endoscopy and colonoscopy in the next step of the management of the patient with significant weight loss. Total colonoscopy was unremarkable and esophagogastroduodenoscopy demonstrated a sessile polyp in antrum pathologically consistent with hyperplastic polyp. His spiral chest CT scan was normal but an abdominopelvic CT scan revealed dilation of intrahepatic ducts disseminated all over the liver prominently in the periphery of the right hepatic lobe. Periductal parenchyma was enhanced in some parts indicative of infective or neoplastic processes. Scattered celiac and mesentric lymph nodes with maximum diameter of 6 mm were also detected (figure 1). To have a better visualization of extrahepatic ducts besides intrahepatic ducts, an endoscopic ultrasound (EUS) was performed. As reflected in figure-2, findings of EUS were unremarkable except for 3 hypoechoic and round hilar lymph nodes with the largest diameter of 21mm, most probably indicative of reactive lymph nodes. This patient’s signs and symptoms continued to remain stable, so he was discharged and was advised to follow other diagnostic modalities in the outpatient clinic. Some months later, he referred to the gastroenterology clinic with similar complaints of inability to weight gain and anorexia. Given the previous history of intrahepatic duct dilation, an MRCP was demanded which revealed heterogeneity of the liver parenchyma due to multiple masses or microabscesses in the liver. Laboratory results were negative for infectious, helminthic and parasitic disorders for this kind of liver involvement, and imaging reports were unable to rule out a neoplastic process and give a definite diagnosis. This made us proceed with a liver biopsy. What is your diagnosis? What is the next step? Received: 24 September 2020 Accepted: 8 December 2020 Reprint or Correspondence: Saeed Abdi, MD. Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: saeedabdi75@yahoo.com ORCID ID: 0000-0002-2375-3748

Epidemiology of Traumatic Spinal Cord Injury in the Netherlands: Emergency Medical Service, Hospital, and Functional Outcomes.

Evaluating treatment of traumatic spinal cord injuries (TSCIs) from the prehospital phase until postrehabilitation is crucial to improve outcomes of future TSCI patients. To describe the flow of patients with TSCI through the prehospital, hospital, and rehabilitation settings and to relate treatment outcomes to emergency medical services (EMS) transport locations and surgery timing. Consecutive TSCI admissions to a level I trauma center (L1TC) in the Netherlands between 2015 and 2018 were retrospectively identified. Corresponding EMS, hospital, and rehabilitation records were assessed. A total of 151 patients were included. Their median age was 58 (IQR 37-72) years, with the majority being male (68%) and suffering from cervical spine injuries (75%). In total, 66.2% of the patients with TSCI symptoms were transported directly to an L1TC, and 30.5% were secondarily transferred in from a lower level trauma center. Most injuries were due to falls (63.0%) and traffic accidents (31.1%), mainly bicycle-related. Most patients showed stable vital signs in the ambulance and the emergency department. After hospital discharge, 71 (47.0%) patients were admitted to a rehabilitation hospital, and 34 (22.5%) patients went home. The 30-day mortality rate was 13%. Patients receiving acute surgery (<12 hours) compared to subacute surgery (>12h, <2 weeks) showed no significance in functional independence scores after rehabilitation treatment. A surge in age and bicycle-injuries in TSCI patients was observed. A substantial number of patients with TSCI were undertriaged. Acute surgery (<12 hours) showed comparable outcomes results in subacute surgery (>12h, <2 weeks) patients.

Sudden unexpected death after acute symptomatic seizures in a patient on mechanical ventilation

BackgroundThe mechanism of sudden unexpected death in epilepsy remains poorly understood. Seizure induced cardiac arrhythmia, central and obstructive apneas have been proposed as possible causes of death. Here we report a unique case of seizure related sudden unexpected death in a patient whose airway was fully protected by intubation and mechanic ventilation in the absence of fatal cardiac arrhythmia.Case presentationA 70-year-old woman was undergoing mechanical ventilation and video-electroencephalography (EEG) monitoring following two convulsive seizures with ictal hypoventilation and hypoxemia. Several hours after intubation, she suffered another generalized tonic clonic seizure lasted for 3 min and developed postictal generalized EEG suppression in the presence of stable vital signs with SpO2 > 90%. EEG suppression persisted throughout the postictal phase. There was a significant fluctuation of systolic blood pressure between 50 and 180 mmHg with several bouts of hypotension < 60 mmHg. She remained unresponsive after the convulsive seizure and died of diffuse cerebral edema 12 h later. Autopsy revealed no clear cause of death, except for possible hypoxic and ischemic injury leading to the diffuse cerebral edema.ConclusionGiven the reliable periictal airway protection, neither seizure induced central apnea nor obstructive apnea appeared to be the direct cause of death in this unique case. In the absence of fatal cardiac arrhythmia, diffuse cerebral edema secondary to seizure-induced autonomic dysfunction, hypotension and hypoxemia might be the cause of death, highlighting the etiological heterogeneity of sudden unexpected death in epilepsy.

Analysis of percutaneous kyphoplasty under different types of anesthesia for the treatment of multiple osteoporotic vertebral fractures

BackgroundSurgeons recognize that using percutaneous kyphoplasty (PKP) under local anesthesia to treat osteoporotic vertebral fracture (OVF) prevents interference with the general situation of elderly patients suffering from multiple organ dysfunction. Surgeons can directly assess whether nerve injury occurs while the patient is awake. However, when patients with multiple osteoporotic vertebral fractures (m-OVFs) receive local anesthesia, fluoroscopy time often has to be increased, the operative time has to be extended, or the operation has to be terminated because of discomfort related to body posture. No relevant study has thus far been conducted on the type of anesthesia to administer to patients undergoing PKP for m-OVFs. This study aimed to determine which of the two types of anesthesia is more suitable for PKP for m-OVFs.MethodsA retrospective study was conducted involving 159 patients who underwent PKP for m-OVFs from January 2016 to January 2020; 81 patients underwent PKP under general anesthesia (Group G), and 78 patients underwent PKP under local anesthesia (Group L). Clinical and adverse events were compared between the two groups.ResultsThe intraoperative mean arterial pressure, average heart rate, average fluoroscopy times of each vertebral body, and operative time were less in Group G than in Group L. The visual analog scale (VAS) score was significantly lower after than before the operation. The anterior vertebral height (AVH), middle vertebral height (MVH), and kyphotic angle (KA) were significantly improved in both groups postoperatively. The improvement in VAS score, AVH, MVH, and KA in Group G were higher than those in Group L. No significant difference in the incidence of complications was observed between the two groups.ConclusionPKP under either general anesthesia or local anesthesia was reliable. Compared with PKP under local anesthesia, PKP under general anesthesia could more reliably maintain the stability of vital signs, alleviate preoperative pain in patients, and attain a better orthopedic effect. Moreover, the latter does not increase the complications of patients with m-OVFs. However, the high medical expense of PKP under general anesthesia is a factor to consider when choosing the type of anesthesia.

“CHYLO,” IS IT ME YOU'RE LOOKING FOR? A CASE OF TRANSUDATIVE CHYLOTHORAX

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chylothorax is an uncommon type of pleural effusion which is usually exudative in nature. Transudative chylothoraces are an exceedingly rare entity, about 40% of which can be attributed to liver cirrhosis. CASE PRESENTATION: A 69-year-old female with hypertension, IDDM, and NASH/liver cirrhosis, presented with 5 days of shortness of breath and increasing abdominal girth. Examination revealed an obese, ill-appearing female, with stable vital signs, tachypnea requiring 4 L nasal cannula, diminished breath sounds over RM and RL lobes with dullness to percussion, ascitic abdomen without tenderness, without jaundice or other stigmata of liver disease. Laboratory panel was significant for lactic acidosis of 5 mmol/L and hypoalbuminemia. Imaging revealed a large right-sided pleural effusion and moderate ascites. She received aggressive IV fluids, empiric antibiotics, and underwent diagnostic thoracentesis consistent with a transudative effusion. Pleural fluid revealed a “milky” substance; triglyceride level was therefore checked with a value over 200 mg/dL. Her gram stain and culture were negative. Cytology was unremarkable. Patient had no history of trauma or surgeries. CT imaging had no evidence of lymphadenopathy or chronic lung changes. Echocardiogram ruled out CHF and pericarditis. A rheumatic panel was negative. There was no eosinophilia to suggest a parasitic infection. Quantiferon was negative. Paracentesis could not be performed due to small volume of ascites. Chest tube was placed for symptom relief. Given drainage of over 1 L output per day, total parenteral nutrition (TPN), chyle leak diet, and octreotide were started. Chest tube was removed after 10 days given decreasing output. Repeat pleural analysis showed a triglyceride level of 17 mg/dL. TPN was stopped and she was transitioned to a regular diet. Her chylothorax was attributed to liver cirrhosis. She was started on diuretics and discharged home with close follow-up. DISCUSSION: Emphasis must be placed on reviewing all aspects of the pleural fluid analysis including color, with chylothorax on the differential. Transudative chylothorax formation likely occurs due to chylous ascites transmigration through the diaphragm, with cirrhotic portal hypertension causing increased pressure in the thoracic duct. Once trauma is eliminated, malignancy, CHF, SVC obstruction, infections, sarcoidosis, and rheumatologic causes should be ruled out. Treatment relies on decreasing thoracic duct volume and inhibiting intestinal chyle absorption via somatostatin analogues, thoracentesis, and diet. Diuretics and transjugular intrahepatic portosystemic shunting were further treatment options for our patient given her liver cirrhosis. CONCLUSIONS: As transudative chyloraces are rare, clinicians may fail to recognize cirrhosis on the differential and fail to treat the underlying cause. Reference #1: Bhardwaj, Himanshu, et al. “Transudative Chylothorax in a Patient with Liver Cirrhosis: A Rare Association.” Heart & Lung, vol. 44, no. 4, 1 May 2015, pp. 363–365., doi:10.1016/j.hrtlng.2015.03.008. Reference #2: Mukherjee, Arindam, et al. “Transudative Chylothorax: an Uncommon Illness Due to a Common Cause.” BMJ Case Reports, 19 Jan. 2018, doi:10.1136/bcr-2017-223158. Reference #3: Schild, Hans H., et al. “Treatment Options in Patients With Chylothorax.” Deutsches Aerzteblatt Online, vol. 110, no. 48, 2013, pp. 819–826., doi:10.3238/arztebl.2013.0819. DISCLOSURES: No relevant relationships by Robert Gallagher, source=Web Response No relevant relationships by Loren Inigo-Santiago, source=Web Response No relevant relationships by Polina Pinkhasova, source=Web Response

S2385 Hepatic Artery Vasculitis: Very Unique Presentation of a Single Organ Vasculitis

INTRODUCTION: Vasculitis usually has a systemic involvement. Rare cases of localized vasculitis have been described, but the exclusive involvement of the hepatic artery is exceptionally rare. We report the case of a patient who developed vasculitis of the right and left hepatic arteries as a very rare presentation of single organ vasculitis. CASE DESCRIPTION/METHODS: A 47-year-old Lady with no medical history was admitted with epigastric discomfort for a couple of weeks. The pain was sharp, localized and progressive. She reported bloating, nausea, and episodes of vomiting, but denied, fever, chills, melena, or other complaints. She was afebrile with stable vital signs and normal examination otherwise. There was minimal tenderness on deep palpation of the epigastrium and right upper quadrant without distension, guarding, or rigidity. Complete blood count and comprehensive metabolic panel including liver enzymes were normal. CRP and ESR were both elevated at 9.2 mg/dL and 62 mm/hr, respectively, but amylase and lipase were normal. CT scan showed diffuse mural thickening with luminal narrowing of the hepatic artery extending into the distal celiac trunk and proximal few millimeters of the splenic artery. These findings are most likely due to vasculitis. Tests for for anti-neutrophil cytoplasmic antibodies, ANA, RF, cryoglobulins, antiphospholipid antibodies, hepatitis B and C serology, HIV serology and the complement levels were all uneventful. Given these radiologic findings, elevated sedimentation rate, CRP, and the evaluation for systemic vasculitis, the patient was treated as isolated Hepatic artery vasculitis. She was started on pulse dose methylprednisolone intravenously for 3 days, after which her ESR and CRP normalized and her symptoms resolved. She was discharged home on prednisone which was later tapered off during clinic follow up. DISCUSSION: Vasculitis usually has a systemic involvement. The exclusive involvement of the hepatic artery of localized vasculitis is very rare, that’s why it’s mandatory to go through full work up for systemic vasculitis to be ruled out. Very few cases of localized vasculitis have been described, but the exclusive involvement of the hepatic artery is exceptionally rare. The outcome was favorable with corticosteroid therapy alone.Figure 1.: CT of the abdomen indicates the common hepatic artery with a thickened rind of soft tissue density and mild stranding in the adjacent fat.Figure 2.: Ct abdomen and pelvis coronal section, the red dot represent the area of hepatic artery with a thickening.Figure 3.: Abdomen and pelvis CT scan sagittal section, the red dot represent the area of hepatic artery with a thickening.

S2404 Acute Fatty Liver of Pregnancy in the Early Second Trimester Masquerading as Autoimmune Hepatitis

INTRODUCTION: Acute fatty liver of pregnancy (AFLP) is a rare and potentially fatal condition characterized by microvesicular steatosis and liver failure. It typically presents in the third trimester or early postpartum period, but several cases have been described in the second trimester, with the earliest reported case at 18 weeks gestation. Diagnosis is based on the Swansea Criteria, though liver biopsy can be performed under certain circumstances. Treatment involves supportive care and prompt fetal delivery, with recovery expected over the ensuing days to weeks. We present the earliest known case of AFLP at 15 weeks gestation and detail how its clinical course masqueraded as autoimmune hepatitis (AH). CASE DESCRIPTION/METHODS: A 41-year-old G4P2103 with morbid obesity was transferred to our institution with jaundice, scleral icterus, and vomiting after laboratory testing revealed AST 51 IU/L, ALT 88 IU/L, ALP 191 IU/L, and TB 15 mg/dL. On admission she was alert and oriented with stable vital signs. Laboratory testing was notable for an ANA with >1:1280 titer. Additional autoantibodies, anti-cardiolipin, and ADAMTS13 were negative. Blood smear showed no hemolysis. On day 2 an abdominal ultrasound revealed intrauterine fetal demise, so dilation and evacuation were performed. There was no evidence of preeclampsia or hemolysis with elevated liver enzymes and low platelets, so she was treated with methylprednisolone out of concern for AH. She did not improve with steroids so liver biopsy was performed which revealed mixed micro- and macrovesicular steatosis consistent with AFLP and nonalcoholic fatty liver disease (NAFLD). She was transferred to a liver transplant center where she expired without further intervention. DISCUSSION: This case was challenging because AFLP has never been reported in the early second trimester and the presence of high ANA titers suggested an autoimmune etiology. The biopsy showed mixed micro- and macrovesicular steatosis with cytoplasmic ballooning, mild inflammation, and no fibrosis. AH was excluded due to the lack of interface hepatitis, rosettes, plasma cell inflammatory changes, or improvement with steroids. Although NAFLD is associated with autoantibodies it does not cause acute liver failure, which this patient experienced despite receiving the standard of care. Therefore, based on the patient's clinical course and biopsy we present the earliest case of AFLP complicated by concomitant NAFLD.Figure 1.: Low power, hematoxylin and eosin (H&E) stained section showing mild steatosis in a zonal pattern, primarily involving zone 3. The inflammation is mild with a lobular predominance, composed principally of lymphocytes and plasma cells with smaller populations of neutrophils and eosinophils.Figure 2.: High power, hematoxylin and eosin (H&E) stained section showing cytoplasmic ballooning of hepatocytes with the presence of Mallory's Hyaline (arrows).Figure 3.: High power, hematoxylin and eosin (H&E) stained section of microvesicular (arrowheads) and macrovesicular (asterisk) steatosis.

S3362 Hermansky-Pudlak Syndrome: A Rare Cause of Postpolypectomy Bleeding: A Case Report and Review of Literature

INTRODUCTION: Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic therapy. The rate of PPB to be 0.4% per colonoscopy performed in patients at a high risk of colon polyps. However, the risk of post polypectomy bleeding is higher in patients with bleeding diathesis or platelet dysfunction. Here we report an interesting case of PPB in a patient with bleeding diathesis due to Hermansky-Pudlak syndrome. CASE DESCRIPTION/METHODS: A 68 year old Hispanic man of Puerto Rican descent presented to emergency department with 2 day history of small amount of hematochezia twice daily . One day prior to this event he underwent screening colonoscopy which showed 2 polyps (12 and 14 mm in size) which were removed with the help of a hot snare polypectomy. Post- intervention hemostatic clip and epinephrine were injected. Pathology showed inflammatory polyps. He had medical comorbids of hypertension and Hermansky Pudlak Syndrome . On initial examination in the emergency department, patient was afebrile, with stable vital signs. His abdominal examination revealed no tenderness and digital rectal examination showed brown stool with no hematochezia. Rest of the review of systems and physical examination was unremarkable. Laboratory tests showed a decrease in hemoglobin from a baseline of 13 gm/dl to 11.0 gm/dl. Rest of the laboratory work up was unremarkable. Hematology service was consulted in view of underlying condition and advised to give DDAVP (1-desamino-8-D-arginine vasopressin). Patient was admitted to the medicine floor for observation. He did not have any further episodes of rectal bleeding and his hemoglobin level remained stable during this time. Subsequently he was discharged with outpatient gastroenterology follow up. DISCUSSION: Hermansky-Pudlak syndrome(HPS) is a rare autosomal disorder characterized by oculocutaneous albinism, a bleeding diathesis secondary to platelet dysfunction, and other organ involvement specific to certain types including granulomatous colitis and pulmonary fibrosis. HPS is very uncommon with a prevalence of 1 in 1000,000, However, it is common in Puerto Ricans, affecting approximately 1 in 1,800 people. There is no definitive treatment for HPS. Our goal is to guide the appropriate management of these patients specially perioperatively in major and minor procedures such as routine screening colonoscopies to prevent any adverse events.

Minimally Invasive Injection to the Phrenic Nerve in a Porcine Hemidiaphragmatic Paralysis Model: A Pilot Study.

Neurodegenerative diseases and spinal cord injury can affect respiratory function often through motor neuron loss innervating the diaphragm. To reinnervate this muscle, new motor neurons could be transplanted into the phrenic nerve (PN), allowing them to extend axons to the diaphragm. These neurons could then be driven by an optogenetics approach to regulate breathing. This type of approach has already been demonstrated in the peripheral nerves of mice. However, there is no established thoracoscopic approach to PN injection. Also, there is currently a lack of preclinical large animal models of diaphragmatic dysfunction in order to evaluate the efficacy of potential treatments. To evaluate the feasibility of thoracoscopic drug delivery into the PN and to assess the viability of hemidiaphragmatic paralysis in a porcine model. Two Landrace farm pigs underwent a novel procedure for thoracoscopic PN injections, including 1 nonsurvival and 1 survival surgery. Nonsurvival surgery involved bilateral PN injections and ligation. Survival surgery included a right PN injection and transection proximal to the injection site to induce hemidiaphragmatic paralysis. PN injections were successfully performed in both procedures. The animal that underwent survival surgery recovered postoperatively with an established right hemidiaphragmatic paralysis. Over the 5-d postoperative period, the animal displayed stable vital signs and oxygenation saturation on room air with voluntary breathing. Thoracoscopic targeting of the porcine PN is a feasible approach to administer therapeutic agents. A swine model of hemidiaphragmatic paralysis induced by unilateral PN ligation or transection may be potentially used to study diaphragmatic reinnervation following delivery of therapeutics.

Effect of albumin administration on outcomes in hypoalbuminemic patients hospitalized with community-acquired pneumonia (ALBUCAP): a prospective, randomized, phase III clinical controlled trial\u2014a trial protocol

BackgroundCommunity-acquired pneumonia (CAP) remains a leading cause of death worldwide, and hypoalbuminemia is associated with worse outcomes. However, it remains uncertain whether albumin administration could have any beneficial effects. We aim to assess whether the administration of albumin in hypoalbuminemic patients with CAP increases the proportion of clinically stable patients at day 5 compared with the standard of care alone.MethodsThis is a trial protocol for a superiority, non-blinded, multicenter, randomized, phase 3, interventional controlled clinical trial. The primary endpoint will be the proportion of clinical stable patients at day 5 (intention to treat), defined as those with stable vital signs for at least 24 h. The secondary endpoints will be time to clinical stability, duration of intravenous and total antibiotic treatment, length of hospital stay, intensive care unit admission, duration of mechanical ventilation and vasopressor treatment, adverse events, readmission within 30 days, and all-cause mortality. The trial has been approved by the Spanish Medicines and Healthcare Products Regulatory Agency. The investigators commit to publish the data in peer-reviewed journals within a year of the study completion date. Subjects will be recruited from three Spanish hospitals over a planned enrolment period of 2 years. A follow-up visit will be performed 1 month after discharge. We have estimated the need for a sample size of 360 patients at a two-sided 5% alpha-level with a power of 80% based on intention to treat. Eligible participants must be hospitalized, hypoalbuminemic (≤ 30 g/L), non-immunosuppressed, adults, and diagnosed with CAP. They will be randomly assigned (1:1) to receive standard care plus albumin (20 g in 100 mL) every 12 h for 4 days or standard care alone.DiscussionIf this randomized trial confirms the hypothesis, it should lead to a change in current clinical practice for the management of hypoalbuminemic patients with CAP.Trial registrationEuropean Clinical Trials Database (EudraCT) 2018-003117-18. Registered on 12 April 2019. ClinicalTrials.gov NCT04071041. Registered on 27 August 2019

A Case Report of a Young Pregnant Woman with Preeclampsia and Acute Pulmonary Edema in Severe Transient Heart Failure

Introduction: Young pregnant woman (32 weeks) following one-month illnessesm, including peripheral edema, paresthesia and shortness of breath, for which no specific diagnosis was made in the evaluations; she was hospitalized with severe respiratory distress and pulmonary edema. Re-examination revealed severe systolic heart failure (left ventricular ejection fraction: 10-15%) with preeclampsia. After the relative stabilization of the patient's vital signs, the pregnancy was terminated. One week after termination of pregnancy, the patient's heart failure improved.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review.

IntroductionHepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis.MethodsWe reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed.ConclusionsThe management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

Minimally invasive surgical management of Boerhaave's syndrome: a narrative literature review.

Treatment of Boerhaave’s syndrome is controversial. Formal thoracotomy and laparotomy were considered the gold standard treatment in the past. However, these approaches are associated with significant surgical trauma, stress, and postoperative pain. Recently published studies reported the application of minimally invasive surgery in the setting of such esophageal emergency. However, the application of minimally invasive surgery in the setting of Boerhaave’s syndrome is debated and evidence is puzzled. The aim of this study was to summarize the current knowledge on minimally invasive treatment of Boerhaave’s syndrome. PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of Boerhaave’s syndrome in the setting of minimally invasive surgery (thoracoscopy or laparoscopy) were included. Sixteen studies and forty-eight patients were included. The age of the patient population ranged from 37 to 81 years old and 74% were males. The time shift period from symptoms onset to surgical treatment ranged from 5 to 240 hours with 10 patients (20.8%) having surgery more than 24 hours from symptoms onset. Vomiting (100%), chest/epigastric pain (88%), and dyspnea (62%) were the most commonly reported symptoms. The perforation size ranged from 6 to 30 mm with 96% of patients suffering from distal esophageal tear. Video-assisted thoracoscopy (VATS) was the most commonly reported surgical approach (75%), followed by laparoscopy (16.7%), and combined thoraco-laparoscopy (6.2%). In case of VATS, a left approach was adopted in 91% of patients with selective lung ventilation. Primary suture was the most commonly performed surgical procedure (60%) with interrupted single or dual-layer repair. Surgical debridement (25%), primary repair reinforced with gastric or omental patch (8%), esophageal repair over T-tube (6%), and endoscopic stenting combined with laparoscopic debridement (2%) were also reported. The postoperative morbidity was 64.5% with pneumonia (42%), pleural empyema (26%), and leak (19%) being the most commonly reported complications. The overall mortality was 8.3%. Boerhaave’s syndrome is a rare entity. Minimally invasive surgical treatment seems promising, feasible, and safe in selected patients with early presentation and stable vital signs managed in referral centers. In the management algorithm of Boerhaave’s syndrome, a definitive indication to adopt minimally invasive surgery is lacking and its potential role mandates further analysis.