Weeks Of Symptom Onset Research Articles

Which sampling method for the upper respiratory tract specimen should be taken to diagnose patient with COVID-19?

Coronavirus disease 2019 (COVID-19) is raging in China, especially in Hubei Province, which has resulted great dangers in people's life and national economy. According to the guidelines drafted by China's Center for Disease prevention and Control (CDC), the positive nucleic acid test is need to the diagnosis of patient with COVID-19. Upper respiratory tract specimens are the main sources for nucleic acid detection. However, based on international guidelines of COVID-19 , no recommended level of upper respiratory tract sampling method is proposed. Therefore, which kind of sampling methods should be chosen to help the COVID-19 diagnosis and which way is the most secure for doctors and nurses is our concern. In this review, we analyzed a total of 10 literatures on the sampling methods of upper respiratory tract related to infectious diseases such as severe acute respiratory syndrome coronavirus (SARS), middle east respiratory syndrome coronavirus (MERS), and influenza A (H1N1), which were spread worldwide in past years. Literatures were collected from the three dimensions of sampling method, sampling time, and sampling safety. It was found that among all the upper respiratory sampling methods, nasopharyngeal aspirate (NPA) had a higher positive rate within 2 weeks of symptom onset, while combined nasal and oropharyngeal swabs (NS + OPS) was the least harmful to medical staff during sampling. We wish this review is helpful for the prevention of COVID-19. Key words: Coronavirus; Nucleic acid detection; Upper respiratory tract; Sampling method; Nasopharynx aspirate

Poor clinical outcomes for patients with cancer during the COVID-19 pandemic.

Poor clinical outcomes for patients with cancer during the COVID-19 pandemic.

Postoperative outcomes in thoracic outlet decompression for acute versus chronic venous thoracic outlet syndrome

ObjectiveVenous thoracic outlet syndrome (VTOS) is a rare disorder that occurs in young athletes and working adults. There are multiple published reports demonstrating excellent outcomes with thoracic outlet (TO) decompression surgery when patients present acutely (within 2 weeks of symptom onset). Our objective was to assess outcomes after decompression surgery in patients with acute, subacute, chronic, and secondary VTOS. Additionally, we sought to identify risk factors for persistence of symptoms following operative decompression. MethodsA retrospective chart review was performed for all patients who underwent operative decompression for VTOS at the University of Pittsburgh Medical Center from 2013 to 2017. We examined baseline characteristics, comorbidities, presenting symptoms, interventions performed, and postoperative clinical outcomes. Patients were characterized as acute, subacute, or chronic based on onset of symptoms and presentation to our surgeons (acute <2 weeks, subacute 2 weeks to 3 months, and chronic >3 months). Our outcomes of interest were return to baseline functional status as defined by resumption of sports activity or occupation and axillosubclavian vein patency. ResultsA total of 51 operative decompressions were performed in 48 patients for VTOS. There were 23 operations (45%) performed on patients who presented acutely, 7 (14%) in the subacute group, and 21 (41%) surgeries in patients with chronic symptoms. Of these 51 operations, 4 (7.8%) were deemed unsuccessful—two surgeries were in the acute group, one in the subacute, and one in the chronic group. The 30-day morbidity after 51 first rib resections included no pneumothoraces, no lymphatic leaks, two surgical site hematomas with associated hemothorax in one patient, two surgical site infections, and only two unplanned returns to the operating room for hematoma evacuation and superficial wound infection washout. In terms of preoperative vein patency, those who presented acutely were more likely to have an occluded axillosubclavian vein (P = .029). The Fisher's exact was 0.540, indicating that the proportion of patients returning to baseline functional status were similar when comparing acute presenters with those who present late. A multivariate Cox proportional hazards model was attempted; however, a small sample size greatly limited the power of the study and prohibited identification of risk factors for surgical failure. ConclusionsPatients with acute and chronic VTOS resumed their preintervention sports activity or vocation after TO decompression in more than 90% of cases with a low incidence of adverse events. Based on our study results, patients with chronic VTOS benefit as much from TO decompression as those with acute VTOS.

Technology-enabled longitudinal monitoring of patient-reported outcomes (PROs) to individualize care of immune-related adverse events (irAEs) in patients (pts) treated with immune checkpoint inhibitors (ICIs).

TPS2088 Background: ICIs have become the therapeutic standard for many cancers but are associated with unique and diverse irAEs that often occur at home. Appropriately timed and specific interventions are critical to recovery. Thus, there is a need to effectively &amp; efficiently monitor in real time pts treated with ICIs. To improve outcomes, we have activated a clinical trial developed to determine the feasibility and safety of an electronically enabled strategy to remotely monitor symptoms and prompt communication that will guide and inform specific patient-driven “course corrections” in response to potential irAEs. Methods: This is an adaptive prospective trial that uses a mobile irAE-specific PRO application we developed to monitor and alert the care team in real time when severe symptoms are reported. In parallel with the mobile symptom collection, serum and urine biomarkers are collected at baseline, first tumor restaging, and upon the development of irAEs. Optional stool microbiome analyses are also performed. To facilitate the generalizability of our inferences, we are using broad inclusion criteria: ECOG performance status ≤3; any line of ICI given as standard of care or as part of therapeutic clinical trials; elderly pts are included. Because the relationship between PROs and irAEs is currently undefined, we designed our trial to use adaptive symptom thresholds that will notify the healthcare team of suspicion for irAEs. The mobile application will use these dynamic thresholds to determine whether or not to alert the healthcare team. The positive and negative predictive value of each symptom for identifying subsequent irAEs will be assessed at scheduled interim analysis time points. The care teams’ responses to the alerts, and all of the clinical outcomes for the pts over time will be collected as part of the trial. The primary goal of the trial is the assessment of the predictive power of the mobile PRO symptom collection in combination with serum and urine markers to identify grade 2 or higher adverse events that require intervention (e.g., dose modifications, hospitalizations, and therapeutic interventions) within two weeks of symptom onset. Effective remote monitoring of irAEs will leverage our understanding of ICI toxicity and empower pts to be effective partners in their care. The trial has currently enrolled 17 pts towards the enrollment target of 100 pts. Clinical trial information: PA19-0095 .

Referring early arthritis patients within 6 weeks versus 12 weeks after symptom onset: an observational cohort study.

The first recommendation of the European League Against Rheumatism for the management of early arthritis states that patients should be referred to, and seen by, a rheumatologist within 6 weeks after symptom onset. However, implementation of this recommendation is a challenge, and evidence supporting this timeframe compared with longer timeframes is absent. Therefore, we aimed to investigate whether visiting a rheumatologist within 6 weeks of symptom onset relates to improved long-term outcomes compared with visiting a rheumatologist between 7 and 12 weeks after symptom onset. In this observation cohort study, consecutive patients with rheumatoid arthritis from the Leiden Early Arthritis Clinic (EAC) and the French Etude et Suivi des Polyarthrites Indifferenciées Recentes (ESPOIR) were included. In this analysis, we included patients who were diagnosed with rheumatoid arthritis and classified according to 1987 American College of Rheumatology criteria, and with symptom onset and remission data available. Patients were categorised into groups based on time between symptom onset and first encounter with a rheumatologist: within 6 weeks, between 7 weeks and 12 weeks, and after 12 weeks. The main outcomes were sustained disease-modifying antirheumatic drug (DMARD)-free remission and radiographic progression. Multivariable Cox regression, linear mixed models, and meta-analyses were used. 1025 patients with rheumatoid arthritis included in the EAC between Jan 1, 1996, and Dec 31, 2017, and 514 patients with rheumatoid arthritis included in ESPOIR between Nov 1, 2002, and April 30, 2005, were included in this analysis. Median follow-up was 7·1 years (IQR 3·9-12·2) in the EAC and 10·0 years (9·0-10·0) in ESPOIR. After 7 years of follow-up in the EAC, 30 (24%) of 127 patients with a time to encounter of 6 weeks or less, 45 (20%) of 223 patients with a time of 7-12 weeks, and 100 (15%) of 675 patients with a time of more than 12 weeks achieved sustained DMARD-free remission. After 10 years of follow-up in ESPOIR, three (27%) of 11 patients with a time to encounter of 6 weeks or less, 11 (11%) of 100 patients with a time of 7-12 weeks, and 41 (10%) of 403 patients with a time of more than 12 weeks had sustained DMARD-free remission. In the EAC multivariable analysis, patients who encountered a rheumatologist within 6 weeks obtained sustained DMARD-free remission more often than those seen between 7 and 12 weeks (hazard ratio [HR] 1·59 [95% CI 1·02-2·49], p=0·042), and after 12 weeks (1·54 [1·04-2·29], p=0·032). In the ESPOIR multivariable analysis, similar but non-significant effects were observed (HR 2·81 [95% CI 0·75-10·53], p=0·12, for within 6 weeks vs 7-12 weeks and 3·05 [0·89-10·49], p=0·077, for within 6 weeks vs more than 12 weeks). The meta-analysis of both cohorts showed that the time to encounter of 6 weeks or less was associated with a higher chance of achieving sustained DMARD-free remission than a time of 7-12 weeks (HR 1·69 [95% CI 1·10-2·57], p=0·016) and a time of more than 12 weeks (1·67 [1·08-2·58], p=0·020). The multivariable analysis showed that patients who encountered a rheumatologist within 6 weeks had similar radiographic progression to those seen between 7 and 12 weeks in both cohorts (β=1·00 [95% CI 0·95-1·05], p=0·96, in the EAC and 0·93 [0·80-1·07], p=0·30, in ESPOIR) and to those seen after 12 weeks (β=0·96 [95% CI 0·92-1·00], p=0·064, in the EAC and 0·89 [0·77-1·02], p=0·10, in ESPOIR). In the meta-analysis, a time to encounter of 6 weeks or less was not associated with less radiographic progression than a time of 7-12 weeks (β=0·99 [95% CI 0·95-1·04], p=0·75) but was associated with less radiographic progression than a time of more than 12 weeks (0·95 [0·91-0·99], p=0·028). Visiting a rheumatologist within 6 weeks of symptom onset had benefits for achieving sustained DMARD-free remission, but not for radiographic progression. European Research Council, Dutch Arthritis Society, Merck Sharp & Dohme, INSERM, The French Society of Rheumatology, Pfizer, AbbVie, Lilly, and Sanofi.

Rapid humoral immune responses are required for recovery from haemorrhagic fever with renal syndrome patients

ABSTRACT Haemorrhagic fever with renal syndrome (HFRS) following Hantaan virus (HTNV) infection displays variable clinical signs. Humoral responses elicited during HTNV infections are considered important, however, this process remains poorly understood. Herein, we have investigated the phenotype, temporal dynamics, and characteristics of B-cell receptor (BCR) repertoire in an HFRS cohort. The serological profiles were characterized by a lowered expression level of nucleoprotein (NP)-specific antibody in severe cases. Importantly, B-cell subsets were activated and proliferated within the first two weeks of symptom onset and moderate cases reacted more rapidly. BCR analysis in the recovery phase revealed a dramatic increase in the immunoglobulin gene diversity which was more significantly progressed in moderate infections. In severe cases, B-cell-related transcription was lower with inflammatory sets overactivated. Taken together, these data suggest the clinical signs and disease recovery in HFRS patients were positively impacted by rapid and efficacious humoral responses.

Change in visual acuity and retinal structures following Repository Corticotropin Injection (RCI) therapy in patients with acute demyelinating optic neuritis: Improvement in low contrast visual acuity in both affected and contralateral eyes in a single-armed open-label study

BackgroundCurrent treatments after an episode of optic neuritis have limited success protecting the retinal nerves and restoring visual function. ObjectiveTo assess the effectiveness of Repository Corticotropin Injection (RCI) after the onset of optic neuritis. MethodsTwenty-four adults were treated with RCI within 2 weeks of symptom onset. Seven exams over 400 days measured low- and high-contrast visual acuity (LCVA and HCVA) and spectral domain optical coherence tomography of the retinal structures. Differences between and among affected and contralateral eyes were assessed using linear mixed models. ResultsHCVA improved in the affected eye over the study (36.2 letters to 52.5), and LCVA improved in both the affected eye (1.8 letters to 6.8) and the contralateral eye (8.3 letters to 11.7). These functional improvements occurred concurrent to a thinning in the papillomacular bundle and the ganglion cell, inner plexiform, and retinal nerve fiber layers, while the inner nuclear, outer plexiform, outer nuclear, and photoreceptor layers thickened. ConclusionThe eyes affected by the ON and treated with RCI improved in both LCVA and HCVA, and unexpectedly LCVA improved in the contralateral eye as well. This functional improvement was mirrored by structural changes in the retina. This study lays the groundwork for future studies to explore potential neuro-protective and neuro-restorative effects of RCI.

Clinical Practice Guideline: Sudden Hearing Loss (Update) Executive Summary.

ObjectiveSudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently, but not universally, accompanied by tinnitus and/or...

Clinical Practice Guideline: Sudden Hearing Loss (Update).

ObjectiveSudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently but not universally accompanied by tinnitus and/or v...

Viral conjunctivitis: a retrospective study in an Australian hospital

ImportanceTo update the literature on the current trends of viral conjunctivitis infections in Sydney, Australia. BackgroundTo find correlations between viral and patient characteristics on disease outcomes and to assess the rates of antibiotic and steroid use in patients with viral conjunctivitis prior to and after assessment by ophthalmology trainees. DesignRetrospective single-centre case series. Participants368 eyes of 224 patients diagnosed with viral conjunctivitis at the Sydney Eye Hospital from 1 st January - 31 st March 2017. MethodsPatients were identified from hospital records or polymerase chain reaction results. Results368 eyes of 224 patients, median age 35.3 (range 7–82) and 59.8% males, were included. 152 (67.9%) patients presented already on antibiotic treatment. Most patients (83.5%) had no previous ocular history aside from 35 (15.6%) who were regular contact lens wearers. PCR was performed in 170 (75.9%) patients, with 92 (54.1%) positive for adenovirus, and 7 (4.1%) for HSV. The average duration of symptoms prior to presentation was 6.3 days. 177 (78.0%) patients presented within 1 week of symptom onset and these patients were more likely to be adenovirus positive on PCR (OR = 2.37). Patients with symptoms of longer duration were more likely to have photophobia (OR = 2.96) and have had steroid treatment (OR = 3.80). Conclusions and relevancePatients with viral conjunctivitis typically presented within a week of symptom onset, with bilateral disease and on topical antibiotics. Pseudomembranes and a palpable preauricular lymph node were not common. As treatments emerge for viral conjunctivitis patients may need to be encouraged to present earlier.

Dengue and Zika Virus Diagnostic Testing for Patients with a Clinically Compatible Illness and Risk for Infection with Both Viruses.

SummaryDengue and Zika viruses are closely related mosquitoborne flaviviruses with similar transmission cycles, distribution throughout the tropics and subtropics, and disease manifestations including fever, rash, myalgia, and arthralgia. For patients with suspected dengue or Zika virus disease, nucleic acid amplification tests (NAATs) are the preferred method of diagnosis. Immunoglobulin M (IgM) antibody testing can identify additional infections and remains an important tool for the diagnosis of these diseases, but interpreting the results is complicated by cross-reactivity, and determining the specific timing of infection can be difficult. These limitations are a particular challenge for pregnant women in determining whether Zika virus infection occurred during or before the pregnancy.This report summarizes existing and new guidance on dengue and Zika virus diagnostic testing for patients with a clinically compatible illness who live in or recently traveled to an area where there is risk for infection with both viruses. CDC recommendations for screening of asymptomatic pregnant women with possible Zika virus exposure are unchanged. For symptomatic nonpregnant persons, dengue and Zika virus NAATs should be performed on serum collected ≤7 days after symptom onset. Dengue and Zika virus IgM antibody testing should be performed on NAAT-negative serum specimens or serum collected >7 days after onset of symptoms. For symptomatic pregnant women, serum and urine specimens should be collected as soon as possible within 12 weeks of symptom onset for concurrent dengue and Zika virus NAATs and IgM antibody testing. Positive IgM antibody test results with negative NAAT results should be confirmed by neutralizing antibody tests when clinically or epidemiologically indicated, including for all pregnant women. Data on the epidemiology of viruses known to be circulating at the location of exposure and clinical findings should be considered when deciding which tests to perform and for interpreting results.Patients with clinically suspected dengue should receive appropriate management to monitor and treat shock and hemorrhage. Women with laboratory evidence of possible Zika virus infection during pregnancy and their infants should be evaluated and managed for possible adverse outcomes. Dengue and Zika virus disease are nationally notifiable conditions, and cases should be reported to public health authorities.

P85-F The utility of MVRCs in detection of early axonal involvement in GBS

Introduction The initial diagnosis of Guillain Barre Syndrome (GBS) may be difficult since electrophysiological changes are usually first seen 2–3 weeks after disease onset. We aimed in this study to examine whether Muscle Velocity Recovery Cycles (MVRCs) may detect early changes in GBS and differentiate demyelinating (Acute Inflammatory Demyelinating Polyneuropathy-AIDP) and axonal (Acute Motor Axonal Neuropathy-AMAN) types. Methods Twelve GBS patients (7 AIDP, 4 AMAN, 1 acute CIDP (chronic inflammatory demyelinating polyneuropathy)) and 24 age-matched healthy controls (HC) were included. In addition to conventional nerve conduction studies (NCS) and electromyography, MVRCs in the anterior tibial muscle were done in the 1st week of symptom-onset. A 4th-week examination by NCS/electromyography was done in all patients and MVRC in 6 (4 AIDP and 2 AMAN). Results Of MVRC parameters, muscle relative refractory period was significantly prolonged and early and late supernormality were reduced in patients compared to HC (t-test, p 0.05). Conclusion Changes in MVRCs already in the 1st week of symptoms before presence of denervation activity may suggest early detection of axonal involvement in GBS. Additionally, MVRC could distinguish AIDP from AMAN, however this could also be due to severity of the disease in these patients.

The Use of Aerosolized Ribavirin in Respiratory Syncytial Virus Lower Respiratory Tract Infections in Adult Immunocompromised Patients: A Systematic Review.

Introduction: Respiratory syncytial virus (RSV)-associated lower respiratory tract infection (LRTI) is a concern in immunocompromised patients. Aerosolized ribavirin (RBV AER) is used for treatment of RSV LRTI; however, adverse events and rising drug costs remain a challenge for patient management. The purpose of this systematic review is to summarize the efficacy and adverse event profile of RBV AER for the treatment of hospitalized RSV LRTI in immunocompromised adult patients. Methods: A Medline/PubMed, Embase, Google Scholar, Clinicaltrials.gov, and Cochrane Library database search was conducted from 1966 to January 2019 for the use of RBV AER. Search strategy: [(ribavirin OR ICN1229) AND ("administration, oral" OR "oral" OR "administration, inhalation" OR "inhalation)] AND ("respiratory tract infection" OR "pneumonia"). Studies were reviewed if adult patients were hospitalized, immunocompromised, had RSV LRTI, received RBV AER, and included the outcome of mortality and/or adverse reactions. Methodological quality was assessed using the Cochrane Collaboration GRADE approach. Results: A total of 1787 records were identified and 15 articles met inclusion criteria: hematopoietic stem cell transplant (HSCT)/bone marrow transplant (n = 8), other malignancy/neutropenic (n = 2), solid organ transplant (n = 5). All of the trials are observational with a low quality rating; therefore, a meta-analysis was not performed. The 30-day mortality in studies that contain >10 patients with HSCT, malignancy, and transplant range from 0 to 15.4%, 6.3%, and 0 to 27%, respectively. Improved mortality was cited in 4 studies when RBV AER started before mechanical ventilation or within 2 weeks of symptom onset. Only 3 studies had comparative mortality data with RBV AER and RBV PO. Adverse reactions were reported in 5 studies and included psychiatric manifestations (anxiety, depression, feeling of isolation; n = 14), wheezing/bronchospasm (n = 6), snowflakes/hail blowing in face (n = 6), and precipitation in ventilator tubing (n = 5). Conclusion: There is a lack of high quality, comparative trials on the use of RBV AER for the treatment of RSV LRTI in adult hospitalized immunocompromised patients. There may be a mortality benefit when RBV AER is initiated early after diagnosis or prior to mechanical ventilation, but requires further study. Patient isolation and psychological effects must be weighed against the benefit of therapy.

Abstract TP423: Risk Factors for Intracranial Hemorrhage in Cerebral Venous Thrombosis

Cerebral venous thrombosis is associated with intracranial hemorrhage. The occurrence of brain bleeding complicates management and is associated with worse outcomes. We aimed to identify clinical and imaging risk factors for intracerebral hemorrhage. We hypothesized that higher clot burden would be associated with a higher risk of intracerebral hemorrhage. Methods: We performed a retrospective analysis of an international, multicenter cohort of patients with cerebral venous thrombosis who underwent CT within 2 weeks of symptom onset and who had a subsequent confirmed diagnosis of CVT on MRV, CTV or DSA. Clinical and imaging features were compared between patients with and without intracranial hemorrhage. Clot burden was assessed by counting the number of thrombosed venous sinuses and veins on confirmatory imaging. Results: We recruited 260 patients with cerebral venous thrombosis from 10 institutions in Europe and Mexico. The mean age was 42 and 74% were female. Intracranial hemorrhage was found in 102 (39%). Intracerebral hemorrhage occurred in 64 (63%), small juxtacortical hemorrhage in 30 (29%), subarachnoid hemorrhage in 24 (24%) and subdural hemorrhage in 11 (11%). Combinations of these types of hemorrhage occurred in 23 (23%). Intraparenchymal hemorrhages in multiple locations occurred in 6 (6%). Older age, presence of hematological disease and superior sagittal thrombosis involvement were significantly associated with presence of hemorrhage. The number of thrombosed venous sinuses was not associated with intracerebral hemorrhage (average number of sinuses/veins involved with hemorrhage 2.1 versus 1.9 without hemorrhage, p=0.4). Conclusion: The high rate of intracranial hemorrhage in cerebral venous thrombosis is not explained by widespread involvement of the venous sinuses. Superior sagittal sinus involvement is associated with the presence of intracranial hemorrhage.

Chronic inflammatory demyelinating polyneuropathy presenting as Guillain-Barre syndrome: A case presentation

Guillain–Barre syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) are immune-related neuropathies and differentiated mainly by disease course. GBS is characterized by a monophasic course, with a clinical nadir within 4 weeks of symptom onset, whereas CIDP typically demonstrates a slowly progressive course with gradual worsening over more than an 8-week period. Both may share common features such as demyelinating polyneuropathy, raised protein in cerebrospinal fluid, and conduction delay or block in nerve conduction study. Here, we present a case who was diagnosed and managed as GBS based on history, clinical presentation, and electrodiagnostic criteria on initial visit. Later on, we revised our diagnosis to acute-CIDP when the patient deteriorated after 8 weeks. This subset of the patient (up to 16% of CIDP) may initially present as GBS. Distinguishing between GBS and CIDP is crucial as prognosis and treatment differ.

739. Middle East Respiratory Syndrome Coronavirus Infection Profile in Qatar: A 7-Year Retrospective Study

BackgroundA deadly zoonotic Middle East respiratory syndrome coronavirus (MERS-CoV) had emerged over the last 7 years in the Arabian Peninsula. As of February 28, 2018, 2,182 cases of MERS-CoV infection (with 779 deaths) in 27 countries were reported to WHO worldwide. The objectives of this study were to identify the clinical and epidemiological characteristics of MERS-CoV infection as well as determine its clinical outcome.MethodsThis was a retrospective-observational study of all laboratory confirmed cases of MERS-CoV infection conducted at the main seven hospitals in the State of Qatar from January, 2012 to April 2018. We used the Fast Track diagnostics real-time reverse-transcription polymerase chain reaction (rRT-PCR), targeting the upE and ORF1a genes respectively. Demographics, clinical information, potential contacts and probable risk factors were collected and analyzed by standard statistical methods.ResultsThe mean annual incidence was 1.7 per 100,0000 person-years. Among the 24 confirmed cases of of MERS-CoV, males constituted the vast majority of cases (23 males) with a median age of 52 years (range 22–74). Fifty percent of the cases were Qatari and 42% reside in the same region. 67% of the cases had contact with camels, and 21% had contact with MERS-CoV-infected patient. Thirty-eight had travel history within 2 weeks of symptoms onset to the Kingdom of Saudi Arabia. Fifty percent were smokers and 42% had comorbidities.The median symptoms duration was 4.5 days. Most of the patient presented with flu-like symptoms, were fever was the most common presentation, followed by cough, SOB, diarrhea, abdominal pain and headache, 96%, 83%, 33%, 8%, 8% and 4%, respectively. All patients were admitted to a tertiary hospital with a median hospital stay 41 days (8–97). Forty-five percent patients developed severe sepsis with multi-organ failure and needed ICU admission. Fifty percent patients developed acute kidney injury, 29% patients were on hemodialysis and 16% needed extra-corporeal membrane oxygenation. Thirty-three percent patients died. The rest of patients had recovered from the infection and discharged home. Among those who died all had one or more comorbidities.Conclusion MERS-CoV infection is a rare infection in the State of Qatar, seen in both Qataris and expatriates with and without travel history. The infection in patients with comorbidities carries high mortality.Disclosures All authors: No reported disclosures.

Growth Hormone Deficiency Is Frequent After Recent Stroke.

Introduction: The incidence of pituitary dysfunction after severe ischemic stroke is unknown, however given the increasing attention to pituitary dysfunction after neurological injuries such as traumatic brain injury, this may represent a novel area of research in stroke.Methods: We perform an arginine and human growth hormone releasing hormone challenge on ischemic stroke patients within a week of symptom onset.Results: Over the study period, 13 patients were successfully tested within a week of stroke (baseline NIHSS 10, range 7–16). Overall, 9(69%) patients had a poor response, with 7(54%) of these patients meeting the criteria for had human growth hormone deficiency. Other measures of pituitary function were within normal ranges.Conclusion: After major ischemic stroke, low GH levels are common and may play a role in stroke recovery.

Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury.

Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury. We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI). Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians (P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years (P = .01), within 6 weeks of symptom onset (P = .03), to question a specific anatomic injury (P = .0001), or by a board-certified hand surgeon (P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs. MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms.

Procalcitonin levels at admission as a predictor of infected pancreatic necrosis in acute pancreatitis

Background: Recognizing a priori potential critical patients that could develop local complications (need of invasive procedures and necrosis infection) during acute pancreatitis (AP) onset is determinant for morbimortality and healthcare costs. The aim of the study was to determine whether higher procalcitonin levels, PCR levels ≥15mg/dL and APACHE-II index ≥8 at admission could predict severity of AP and local complications. Methods: Clinical data of 55 AP patients, prospectively enrolled for study at our institution were analyzed. PCT and PCR levels were dosed and APACHE-II index followed during the first 72 hours since symptomatic onset and patients underwent contrast-enhanced CT within the first week of symptom onset. Patients were divided in two groups: PCT ≥ 2ng/ml and PCT< 2ng/ml. Chi-square and area-under-the-curve receiver-operating characteristics (AUC) were applied. Parameters evaluated were: local complications (pancreatic necrosis infection, need for invasive procedures against necrosis) and AP severity; persistent organ and multiorgan failure (PO, PMOF), admission to intensive care unit (ICU), PA severity according to the Atlanta Classification) and mortality. Results: PCT levels ≥ 2ng/ml outperformed CRP ≥15mg/dl and APACHE-II for transient organ failure (AUC 0.757, p=0.04) and infected necrosis (AUC 0.806, p=0.043). For POF, MOF, mortality, need of intensive care unit, prolonged hospital stay, and need for an invasive procedure, none of the biological markers nor the physiological index showed a decent area under the curve and statistical significance. Conclusion: Procalcitonin levels greater or equal than 2ng/ml more accurately predicts organic failure and necrotic pancreatic infection.

Evaluation of the modified CT severity index (MCTSI) and CT severity index (CTSI) in assessing severity and clinical outcomes in acute pancreatitis

Background: The aim of our study was to compare the MCTSI, CTSI and APACHE II indices for predicting local complications and severity in acute pancreatitis (AP). Methods: Clinical data of 137 patients enrolled prospectively at our institution were analyzed. They underwent contrast-enhanced CT within the first week of symptom onset. Parameters evaluated were: local complications (pancreatic necrosis infection, need for invasive procedures against necrosis) and AP severity (persistent organ failure, admission to intensive care unit (ICU), PA severity according to the Atlanta Classification) and mortality. Chi-square and area-under-the-curve receiver-operating characteristics (AUC) were applied. Results: For local complications, the CTSI index showed little superiority over the MCTSI and APACHE II index in predicting an invasive procedure (AUC 0.824, CI: 0.71–0.94) and pancreatic necrosis infection (AUC 0.823, CI: 0.70–0.95). For AP severity prediction, the MCTSI showed superiority over CTSI and APACHE II for every single criteria evaluated: persistent organ failure (AUC 0.747, CI: 0.64–0.85) AP severity (AUC 0.758, CI: 0.65–0.87), need for ICU (AUC 0.736, CI: 0.61–0.86) and mortality (AUC 0.826, CI: 0.72–0.94). Conclusion: The MCTSI index more accurately predicts acute pancreatitis severity than CTSI and APACHE II. MTCSI is also a good local complications predictor such as need of intervention and pancreatic necrosis infection.