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2021 Southern Medical Research Conference
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Adult clinical symposium

9:30 AM

Thursday, February 25, 2021

1 Recalcitrant iron deficiency anemia and neuropathy as a facade of copper deficiency

N Maaliki*

AA Ali

MB Omar

University of Florida Health at Jacksonville General Medicine, Jacksonville, FL

Introduction

Copper deficiency is a commonly forgotten cause of anemia and myeloneuropathy, especially in malabsorption cases such as gastric bypass.

Case

A 37-year-old lady presents to the clinic due to generalized fatigue, weakness, and bilateral foot pain. She had a past medical history of obesity with Roux-en-Y gastric bypass surgery six months ago. Initial workup revealed profound iron deficiency anemia (IDA), and treatment was started with parenteral and oral replacement. A few months later, her symptoms continued to deteriorate significantly despite aggressive supplemental iron therapy. She had persistent burning pain in both feet, lethargy, weight loss, and pagophagia for ice. Further workup revealed a severe copper deficiency, along with unchanged microcytic anemia. Rapid replacement with oral copper supplementation later improved her symptoms considerably.

Discussion

Copper deficiency is relatively rare and is mostly seen in malnourishment cases. Malabsorption due to gastric bypass surgery has become an increasingly recognized cause. Still, copper levels are not as routinely monitored in the post-operative phase. The main hematologic alteration is anemia, which is often microcytic and hypochromic but may vary due to copper’s intricate involvement in erythropoiesis. More importantly, Copper deficiency can lead to persistent IDA despite aggressive replacement due to impaired iron metabolism, transport, and absorption. Other changes may include leukopenia and occasional neutropenia. Neurologic complications of copper deficiency are myelopathy with or without peripheral neuropathy. Clinically, this manifests in a similar pattern as subacute combined degeneration disease, making the diagnosis even more elusive. Symptoms are commonly localized to the lower extremities, manifesting as a progressive onset of ataxia, decreased sensation, neuropathic pain, and variable muscle paralysis. The treatment includes a rapid replacement of copper by parenteral or oral means.

2 Rapidly fatal autoimmune hemolytic anemia secondary to COVID-19

DW McGregor1*

G Nelson2

C Bergolt1

1VCOM-Auburn, Auburn, AL

2East Alabama Medical Center, Opelika, AL

Case Report

A 75-year-old male presented with complaints of weakness and dyspnea. He noted five days of low appetite, cough, fatigue, and bloody stool. On admission, labs showed a total bilirubin=5.2, MCV=108.3, Hgb=5.6, Hct=16.2; ABG was 7.58/22.7/129 on high-flow nasal cannula 30 L/min. The next day, labs showed an LDH=1,484, haptoglobin <30 and positive direct/indirect Coombs. SARS-CoV2 PCR was positive. IV Methylprednisolone was initiated at 1,000 mg. Within 24 hours shock ensued; respiratory failure developed requiring intubation and transfer to ICU for vasopressors. ID and hematology were consulted: AIHA with COVID-19 cytokine storm and multiorgan failure were diagnosed. Cytokine storm was managed with Actemra 162 mg/.9 ml SubQ. Despite aggressive measures the patient died within 72 hours. Hgb trend during hospital declined from 5.6 mg/d to 3.8 mg/dL despite transfusion.

Discussion

Risks for severe COVID include HTN, CKD, and DM. Our patient had HTN, CKD, and obesity, portending high mortality risk. Average time before AIHA presentation is 4–13 days(1). Our patients Hgb=5.6 gm/dL and Hct=16.2% on intake labs suggest rapid AIHA progression. Current literature supports glucocorticoid use in severe COVID. The RECOVERY trial showed decrease in mortality with dexamethasone of around 30% in oxygen dependent patients(2). Our patient received high dose methylprednisolone, treating both AIHA and COVID cytokine storm. There was delay in obtaining blood product due to his cold agglutinin. While a causative link of AIHA cannot be directly demonstrated, temporality and prior cases strongly support COVID as the cause of hemolytic anemia.1 2 COVID treatment can be broadly grouped into direct viral targeting (remdesevir) and blunting excessive immune response (steroids/interleukin blocking agents). Glucocorticoids are the mainstay of treatment for AIHA and COVID-19, rendering the decision to use steroids during the concurrent presentation a logical choice.

References

  1. Lazarian, et al. ‘Autoimmune hemolytic anemia associated with COVID-19 infection. British Journal of Hematology July 2020.

  2. Hindilerden, et al. ‘Severe autoimmune hemolytic anemia in COVID-19 infection, safely treated with steroids.’ Mediterranean Journal of Hematology and Infectious Diseases, 1 July 2020.

3 Covid encephalopathy with seizures: not a no-brainer

G Dharmarpandi1*

F Etaee1

J Dharmarpandi1

A Akhter2

K Shepherd1

1Texas Tech University Health Sciences Center, Amarillo, TX

2Amarillo VA Health Care System, Amarillo, TX

Case Report

A 72-year-old male with hypertension and coronary artery disease presented with a few hour history of acute aphasia and generalized weakness and a one week history of cough and myalgia. He has no history of CVA or seizures. On admission he had a fever of 100.9F with normal oxygen saturation, clear chest x-ray, and PCR positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CT head showed old thalamic infarct.

Within hours of admission he became more withdrawn with decreasing alertness and ability to follow commands. While pending further investigation, he had two consecutive generalized tonic-clonic seizures. He was given levetiracetam and intubated with no further seizures. Neurologic examination showed the patient was minimally responsive to stimuli with no focal neurological deficits. He was initiated on empiric treatment for bacterial and viral meningitis.

MRI showed acute punctate pontine infarction. EEG showed nonspecific marked diffuse abnormality. Lumbar puncture with elevated WBC at 23 cells/uL, normal glucose, and elevated protein at 248 mg/dL. CSF was negative for every infectious etiology investigated. Based on clinical picture, EEG, MRI, and CSF studies, the patient was determined to have seizures secondary to COVID-induced encephalopathy.

Neurologic manifestations of SARS-CoV-2 are rare, with seizures being even rarer. Documented cases typically present as encephalopathy, encephalitis, and Guillain-Barre syndrome. It remains a diagnosis of exclusion as more common etiologies of encephalopathy and seizures need to be empirically treated and investigated. While it is thought that SARS-CoV-2 can cross the blood brain barrier by way of the olfactory nerve and bind to ACE2 receptors in the brain, there are no current recommendations for Dexamethasone or Remdesivir for neurologic symptoms alone based on the thought that CNS involvement from SARS-CoV-2 is not from the virus itself crossing the blood brain barrier given primary studies showing negative SARS-CoV-2 PCR in the CSF. Also, Remdesivir has poor CSF penetration. Based on the limited data out there regarding seizures due to SARS-CoV-2, antiepileptics like levetiracetam are recommended due to less potential side effects and drug interactions.

4 A curious case of caisson disease

FA Aponte Santos*

N Rassi Stella

NL Rabelo-Pagan

JC Rodriguez Agramonte

R Marrero Fernandez

Universidad de Puerto Rico Escuela de Medicina, Guaynabo, Puerto Rico

Case Report

Decompression sickness is caused by rapid changes in breath air pressure and increased amounts of oxygen and nitrogen in different body tissues. As the diver rapidly ascends, the air pressure substantially decreases creating air bubbles that can obstruct different blood vessels creating a wide variety of complications, including ischemia. With more than 9.5 million licensed divers, only 1,000 approximate cases of decompression sickness are reported per year, making it a rare diagnosis.

A 33 years-old male scuba diver was brought to the ED by ambulance after being found unconscious on the beach shore. Medical history consistent with MDD and cocaine dependence. While en route to the ED, he developed neck pain, and loss of muscle strength. Symptoms developed after five consecutives dives at 115 feet of sea water (fsw) without safety stops nor surface intervals. Spinal MRI was performed with findings consistent with acute isquemia at C6-T2 level. At this point the diagnosis of severe Caisson’s disease was made. Physical exam consisted of severe sensory neurologic impairment at level of T4-T5 dermatome accompanied by motor deficit with inability to flex hips, elevate legs against resistance, and left upper extremities motor deficit at level C8-T1. Immediately after diagnosis Hyperbaric Oxygen Therapy (HBO) was initiated. Follow up spinal MRI showed significant improvement of edema, however, patient’s neurological deficit persisted despite receiving five HBO sessions. At this point the decision to continue HBO was made. After the 12th session neurologic improvement was attained in the lower extremities. The patient completed a total of 20 sessions and regained complete movement and sensation in his body.

This case illustrates the potential complications of decompression sickness and the importance of a prompt identification and rapid treatment to diminish the neurological sequelae and irreversible damage. Identifying precipitant factors that could further aggravate the ischemic symptoms are essential to decide whether the patient will benefit from an extended treatment. The decision to lengthen therapy with

HBO was conclusively beneficial despite delayed neurological improvement. Ultimately, increasing the odds of motor and sensory function recovery.

5 Deep vein thrombosis without laboratory abnormalities as presenting symptom for polycythemia vera

C Kordsmeier*

M Kleinman

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Case Report

Polycythemia vera (PV) is a myeloproliferative disease that is characterized by increased red blood cell mass. One of the major complications of this condition is deep vein thrombosis (DVT). The proposed mechanism for this is thought to be secondary to increased blood viscosity due to the high hematocrit (HCT). However, recent literature suggests that there are multiple other factors that can contribute to DVTs in these patients, including platelet hyperactivity, leukocytosis, and inflammation.

We present the case of a 61 yo black man with no significant past medical history who initially presented for unprovoked unilateral leg swelling and pain, and was subsequently found to have a DVT. The patient had no recent immobility, surgery, or tobacco use. He was on no medications or supplements. He had normal HCT and platelet count at the time of diagnosis. Over the course of following year, he was noted to have progressively increasing HCT. Negative cancer and hypoxemia evaluation led to subsequent genetic testing that confirmed the diagnosis of polycythemia vera with a positive JAK2 V617F mutation. He was subsequently treated with 6 months of anticoagulation and then managed with phlebotomy and hydroxyurea, with no recurrence of thrombosis.

Thrombosis is a common presenting symptom of polycythemia vera, but this case is unique as DVT occurred prior to patient having an abnormal HCT or a diagnosis of PV. This patient illustrates that factors related to PV likely also contribute to thrombosis formation other than red cell mass. Further research is ongoing in this field to locate other risk factors that can lead to thrombosis in patients with PV. Additionally, further discussion is warranted regarding the utility of adding PV screening to the standard workup for patients with DVT without other contributing factors on history.

Abstract 5 Table 1
6 A pain in the neck: an unusual presentation of a retropharyngeal abscess complicated by mediastinitis and internal jugular vein thrombosis

ME Tomaso*

P Yedla

The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

Case Report

A previously healthy 35-year-old male presented to the hospital with five days of high-grade fever and mild posterior neck pain. There were no meningeal signs and he denied a history of recent oropharyngeal infection or trauma. Initial contrast CT of the neck was unremarkable; however, a chest CT was notable for bilateral mediastinal and hilar lymphadenopathy. Two days later, blood cultures returned growing Streptococcus anginosus which prompted a repeat contrast CT of the neck showing a retropharyngeal abscess (RPA) with extension into the right carotid space and superior mediastinum. The abscess was immediately drained and debrided using a flexible laryngoscope and required multiple washouts. This failed to resolve the mediastinitis leading to development of an empyema. Ultimately, the patient required video-assisted thoracoscopic surgery with pulmonary decortication and a prolonged course of antibiotics. The case was further complicated by internal jugular vein thrombosis, which was managed with anticoagulation. The patient was discharged after an extended hospital course and at last follow-up appears to have recovered well.

Retropharyngeal abscesses are rarely seen in adults and the incidence in an immunocompetent adult without history of preceding trauma is unusual. Fewer than five cases of atraumatic adult RPA cases have been reported. This case illustrates the importance of having a high clinical suspicion for RPAs despite negative initial imaging. Two clinical pearls leading to repeat imaging in our case were (a) neck pain out of proportion to oropharyngeal exam and (b) the association of abscess formation with S. anginosus bacteremia in the head and neck. A rapid diagnosis is critical to reducing complications as this infection can spread rapidly through the cervical fascia into the mediastinum. This is a rare complication associated with a very high mortality rate up to 50%.

Neonatal case reports

9:30 AM

Thursday, February 25, 2021

7 Hemolysis in a preterm newborn born to a mother with history of SARS-CoV-2 infection

EC Itriago*

K Lingappan

D Dinu

Baylor College of Medicine, Houston, TX

Introduction

We present a case of a premature newborn born to a mother with known history of SARS-CoV-2 infection during pregnancy, who developed hemolytic anemia, thrombocytopenia and disseminated intravascular coagulation soon after birth.

Case presentation

A 27 weeks preterm baby boy was born by cesarean section due to reversed end-diastolic flow and severe intrauterine growth restriction. Pregnancy was complicated by maternal history of systemic lupus erythematosus, Chron’s disease, and asymptomatic SARS-CoV-2 infection two months before delivery. He required positive pressure in the delivery room and was stabilized on continuous positive pressure. On the day of life (DOL) 1, he was found to be pancytopenic, followed on DOL 2, by mild disseminated intravascular coagulation (DIC), which responded to plasma, red blood cell, and platelet transfusions. There was evidence of intravascular hemolysis with elevated unconjugated bilirubin (7 mg/dL), lactate dehydrogenase (555 U/L), and plasma free hemoglobin (700 mg/dL). Coombs test and antibody screen were negative. Additionally, the patient had normocytic normochromic anemia (hemoglobin nadir 7.2 g/dL), high reticulocyte count, immature reticulocyte fraction, and nucleated red blood cell, as well as schistocytes on peripheral smear. The lupus anticoagulant panel was negative. Head ultrasound reported no intraventricular hemorrhage. The evaluation for sepsis was negative. SARS-CoV-2 antibodies were reactive. He was not tested for SARS-CoV-2 given the history of remote maternal infection and negative test at the delivery.

Discussion

Hemolytic anemia has been reported in adults and children with SARS-CoV-2 infection and an underlying medical condition predisposing to hemolysis, but not in newborns. Growth restricted infants develop thrombocytopenia and neutropenia, usually accompanied by polycythemia, and only in severe cases by anemia, but no hemolysis. Elevated levels of free plasma hemoglobin induce platelet activation and clotting cascade and may explain the mild DIC. While a direct causal relationship between presence of SARS-CoV-2 antibodies and hemolysis cannot be definitively proven, no other etiology for the development of hemolytic anemia was present.

8 Myocardial infarction in a neonate exposed to severe perinatal asphyxia

C Manjunath*

S Liu

E Manci

R Bhat

K Dolma

University of South Alabama, Mobile, AL

Case Report

Neonatal myocardial infarction is very rare, mostly ascribed to congenital cardiac and coronary artery malformations, and thromboembolic events. We hereby report an autopsy case of macroscopic MI in a neonate with normal cardiac anatomy, caused by perinatal asphyxia due to severe fetal anemia. We also report the challenges faced in making an accurate premortem diagnosis as the infant presented with myocardial dysfunction with consequent circulatory failure, which is also seen in infants following perinatal asphyxia.

A 36 wks male was born to a 24 y/o G2P1 mother via vaginal delivery after an uncomplicated pregnancy. At birth, the infant was severely depressed, needing PPV and intubation. The Apgar scores were 1 and 4 at 5 and 10 mins, respectively. ABG revealed severe metabolic acidosis. Signs of severe encephalopathy were noted on the exam; hence, therapeutic hypothermia was initiated. Antibiotics were started. As he continued to remain hypoxemic despite optimal ventilatory support, PGE1 infusion was started for suspected CCHD. CBC revealed severe anemia, for which volume resuscitation with crystalloid fluid and PRBC were done. Echo ruled out the presence of CCHD and confirmed the presence of PPHN. PGE1 was discontinued and iNO was initiated. Despite aggressive measures, the infant rapidly deteriorated with the development of refractory shock, severe liver dysfunction, anuria, DIC, and died on day 3. Autopsy findings revealed both gross and microscopic acute MI in the circumflex artery distribution. It also showed bone marrow dyserythropoiesis with macrocytic, atypical erythroblasts suggesting congenital dyserythropoietic anemia as a probable diagnosis.

Myocardial dysfunction is a known complication in neonates subsequent to perinatal asphyxia. However, in this case report, we describe neonatal MI as a rare manifestation of severe fetal anemia induced perinatal asphyxia. Nevertheless, fetal anemia was due to a rare cause. We speculate that a lack of fetal coronary flow compensation for severe perinatal asphyxia as the coronary vessels was already at their maximum conductance due to fetal anemia, led to the occurrence of watershed MI.

9 Can bronchoscopy be avoided in the diagnosis of congenital bronchobiliary fistula?

AD Haase1*

L Barr2

T Hampton3

J Papic4

G Truong3

1University of Florida, Pensacola, FL

2Ascension Medical Group, Pensacola, FL

3MEDNAX Inc, Pensacola, FL and

4Radiology Partners Inc, Pensacola, FL

Background

Congenital bronchobiliary fistula (CBBF) is a potentially fatal anomaly characterized by an abnormal connection between the respiratory tree and biliary tract. Given its rarity, this lesion represents a unique clinical challenge for rapid identification and treatment. The objective of this report is to familiarize clinicians with this condition and to offer a streamlined diagnostic approach.

Case

A term 2-day-old female presented with rapidly progressive respiratory distress and bilious sputum. Initial diagnostics eliminated intestinal malrotation, midgut volvulus, and tracheoesophageal fistula (TEF). Upon intubation, large amounts of bile were encountered. Chest/abdomen computed tomography (CT) with contrast confirmed an air-filled communication between the carina and the intrahepatic duct. Magnetic resonance cholangiopancreatography was used to rapidly rule out additional commonly associated biliary anomalies. Patient underwent thoracoscopic resection of CBBF and initially did well, but 3 days later deteriorated. Re-exploration with intraoperative cholangiography (IOC) revealed an atretic extrahepatic common bile duct that had ruptured when the source of bile decompression, the CBBF, had been ligated. A drain was placed, and patient subsequently underwent Roux-en-Y hepaticojejunostomy for atresia 9 weeks later. Patient recovered well.

Conclusion

When a neonate presents with bilious emesis, the critical first step is elimination of intestinal obstruction from the differential with an upper GI. An esophogram performed simultaneously can eliminate TEF. If there is no other apparent cause, bronchoscopy as the diagnostic gold standard has gradually been superseded by low dose chest CT and serves as the only exam needed to diagnose CBBF. A biliary system decompressed by a patent fistula decreases reliability of non-invasive imaging techniques thus IOC is imperative to rule out associated biliary anomalies. Neonates are among the most vulnerable for poor outcomes with airway manipulation and the mortality rate in CBBF is already 15.9%. With CT, there is no need to increase risk with bronchoscopy or other non-contributory tests.

10 Utility of ecmo in neonates with hypoxic-ischemic encephalopathy receiving therapeutic hypothermia: a case series

B Johnson*

L Hannah

A Ruiz-Elizalde

A Makkar

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Case Report

About 25% of neonates with Hypoxic Ischemic Encephalopathy (HIE) undergoing therapeutic hypothermia (TH) develop pulmonary hypertension (PHT) and 4–9% of those require ECMO for refractory PHT. Currently, data is limited on the outcomes of patients who undergo both treatments concurrently or sequentially. In this case series, we report two cases of neonates requiring TH for suspected HIE and ECMO for refractory PHT. Patient A was delivered for suspected abruption and met cooling criteria based on seizure activity. He was actively cooling when he qualified for ECMO for severe PHT, with OI of 77. This patient was cannulated and underwent VA ECMO for 4 days which overlapped with the 72-hour of TH. Post cannulation, patient was cooled through the ECMO circuit. Patient B was delivered for Category 2 fetal heart tracings in presence of thick meconium and qualified for TH based on APGAR scoring, physical exam and cord gases. She required ECMO due to worsening PHT, with OI of 40, on the final day of TH. She was cannulated and underwent VV ECMO for 4 days. Patient A developed significant hemolysis due to malpositioning of the circuit pump head; there were no circuit complications for Patient B. Both patients were successfully decannulated and had grossly normal pre-discharge brain MRIs. This case series adds to growing evidence demonstrating ECMO use is feasible and safe in this high-risk population. We recommend individualized decision-making when treating patients with both PHT and HIE and suggest that successful ECMO runs with TH are indeed achievable.

11 Pulmonary hemorrhage: an unusual life-threating presentation of factor ix deficiency in a monozygotic-diamniotic premature twin neonate

LM Pace*

A Lee

S Nath

NJ Alviedo

University of Florida – Jacksonville, Jacksonville, FL

Pulmonary hemorrhage (PH) is a rare, life-threatening condition affecting premature infants. There is no single etiological explanation to PH, but some common denominators include the presence of extreme prematurity, respiratory distress syndrome, surfactant use, birth asphyxia etc. Its incidence is reported to be 0.5% to 11% with a mortality of about 50% [8]. Congenital bleeding disorders such as Hemophilia are rare coagulation disorders that have been known to present in early neonatal period with increased tendency for bleeding after blood draws, circumcision, surgical interventions, intracranial hemorrhage, oral or mucosal bleeding and very rarely as gastrointestinal hemorrhage. There are no reports so far in published literature of Hemophilia presenting as PH in early life. We report an unusual primary presentation of Hemophilia B in a premature, mono-di twin with acute life-threatening PH with no family history of a bleeding disorder.

Abstract 11 Figure 1

AP view of the chest/abdomen showing bilateral hazy opacities. No pleural effusion or pneumothorax were noted

Abstract 11 Figure 2

Post extubation AP view of the chest/abdomen showing significantly improved aeration of both lungs

Abstract 11 Figure 3

Mixing study showing improvement of the aPTT after infant’s splasma was combined with normal plasma

12 Rare presentation of intestinal perforation related to an omphalomesenteric duct in a preterm infant

BR Hadfield*

C Leal

J Doski

M Odom

J Ritter

The University of Texas Health Science Center at San Antonio, San Antonio, TX

Case Report

Omphalomesenteric duct malformations are the most common congenital intestinal anomaly of which Meckel’s diverticulum is the most frequent, occurring in approximately 2% of the population. Complete persistent omphalomesenteric duct (OMD) is rare but can cause serious morbidity and mortality. In this case, we report an intestinal perforation near a patent OMD in a preterm infant who was being treated for necrotizing enterocolitis. On pathologic examination, gastric mucosa was identified within the OMD.

An 830 g SGA male infant was born at 30 weeks gestation following a pregnancy that was complicated by maternal preeclampsia. On DOL 1 he had scant meconium umbilical drainage which resolved spontaneously. Absent further meconium staining at the umbilicus conclusive for a patent OMD, conservative management was elected due to infant size and stability. His subsequent course was complicated by episodes of abdominal distention and emesis. On DOL 36, he developed umbilical erythema and serous umbilical drainage. Cultures of the fluid grew multiple organisms, and he completed an antibiotic course. He progressed to full feeds and did well until DOL 54 when he developed abdominal distension, pneumatosis intestinalis and was diagnosed with necrotizing enterocolitis. Medical management was attempted but on DOL 58 he experienced an abrupt clinical deterioration over an 8 hour period and was found to have pneumoperitoneum. At exploratory laparotomy, an isolated perforation was identified adjacent to the base of an OMD. The OMD was dissected from the base of the umbilicus and resected along with 4 cm of ileum. In the pathological examination, gastric mucosa was identified within the OMD. No evidence of NEC was found within the resected tissue.

This case highlights a rare early presentation of intestinal perforation associated with a patent OMD. Perforation has been reported with Meckel’s Diverticulum, but not with OMD nor in a preterm infant. Furthermore, the case describes the clinical course and complications associated with a patent OMD and may help clinicians in decision making related to management and timing of surgical intervention with OMD in the NICU setting.

Pediatric clinical symposium

9:30 AM

Thursday, February 25, 2021

13 Advanced survival in complete trisomy 13

B Wright*

M Kleinman

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Case Report

Trisomy 13, or Patau Syndrome, is caused by the presence of an extra chromosome 13. It was first described as a clinical syndrome by Patau in 1960 (Patau et al., 1960). The average survival for infants with trisomy 13 is only about 7 days (Duarte et al., 2004). Based on our literature review, there have been six cases of patients with trisomy 13 previously reported who survived past the first decade of life (Redheendran et al., 1981; Singh, 1990; Zoll et al., 1993; Tunca et al., 2001, Iliopoulos et al., 2005). We believe the patient, at 22 years of age, is the longest surviving male with complete trisomy 13. He is a Caucasian male who was born via cesarean section at 39 weeks gestation with a birth weight of 2.41 kilograms. Complete trisomy 13 was diagnosed prenatally by amniocentesis and karyotype. Cesarean section was performed due to congenital anomalies including omphalocele and ventricular septal defect. Other congenital anomalies diagnosed in this patient include cleft lip, cleft palate, Dandy Walker Malformation, coloboma, and dextrocardia. The patient underwent omphalocele repair, and a gastric tube was inserted on day two of life. Other corrective surgeries were done to repair the VSD, cleft lip and palate within the first two years of life. The patient has received nutrition exclusively through his gastric tube. Other major surgical procedures include a monti-Mitrofanoff for neurogenic bladder, hiatal hernia repair, and bilateral pressure equalization tubes. The patient was found to have hypogonadotropic hypogonadism that resulted in severe osteoporosis and growth hormone deficiency. He had a screening DXA scan which showed a Z-score -9.6 in his lumbar spine, and thoracic vertebral compression fractures on x-ray. Despite his complex medical history, he has had infrequent hospitalizations aside from planned surgeries. With aggressive speech, occupational and physical therapy he has developed and maintained some functional skills. The anomaly of this patient’s survival compared to other patients is an interesting study of the wide spectrum of sequela and morbidity from complete trisomy 13. We believe this is consistent with previous studies that early repair of non-lethal heart defects and aggressive medical care in these patients may contribute to prolonged survival (Peterson et al., 2017).

14 An interesting case of chronic recurrent multifocal osteomyelitis (CRMO)

M Patel1*

S Hari Gopal1

Z Choudhury2

R Nelson1

1University of Tennessee College of Medicine at Chattanooga, Chattanooga, TN

2The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Case Report

A 6 year old male was followed by Orthopedics for a 40 day history of right hip pain and antalgic gait. Initial imaging and screening labs were unremarkable. Due to persistent pain, repeat labs showed elevated inflammtory markers. An MRI was obtained as shown in figure 1. The patient was evaluated by Oncology with a bone marrow analysis and cytogenetics. Peripheral blood smear and bone marrow smear showed atypical monocytes. Flow cytometry was negative for a leukemia. Additional infectious labs, including bartonella, blastomycosis, tuberculosis, brucellosis, CMV, and EBV were noted to be negative. ANA and RF were negative. A bone biopsy was obtained, which ruled out langerhans cell histiocytosis. Negative pathology confirmed the diagnosis of CRMO-patient was referred to Rheumatology for further management.

Abstract 14 Figure 1

MRI pelvis showing multifocal marrow signal abnormality with enhancement in the pelvis, proximal femurs

Discussion

CRMO has an incidence ~1–2 per million, with a female predominance and median age of onset at 9–10 years. It can present with a range of severity, commonly involving long bones, clavicle, and manible. 48% of patients with CRMO are not evaluated by rheumatology until 12 months after onset. This delay can lead to irreversible damage, repeated biopsies and radiation exposure. Therefore there should be a high index of suspicion for CRMO in children with chronic bone pain and a negative evaluation.

15 An unwanted souvenir

C Joseph*

N Evans

E Klepper

M Bolton

PC Guillory

Our Lady of the Lake Regional Medical Center, New Roads, LA

Case Report

Although echinococcal disease has a high prevalence worldwide, is it estimated that there are less than one per million inhabitants in the US affected each year. Even rarer, is disease with cysts in multiple body systems.

A six year old female with no past medical history presented to our Emergency Department with complaints of right upper quadrant abdominal pain and distension with associated right neck and shoulder pain. Review of systems was positive for a 2 year long cough, which parents first noted after a trip to Morocco. On exam, she had a palpable abdominal mass, which prompted further imaging that revealed the presence of 2 right lung cysts and 2 liver cysts, the largest measuring 8 × 7 cm. Vancomycin and ceftriaxone therapy were initiated for potential bacterial superinfection. Hydatid disease was suspected and confirmed with echinococcus serology. Due to her rare presentation with both liver and lung involvement, treatment options lay outside current guidelines: lung lesions are typically managed with surgical removal, while liver lesions are typically managed with both anti-parasitics and percutaneous aspiration-injection-reaspiration (PAIR). Our patient was first managed surgically with removal of lung lesions via cystectomy with capitonnage. During the procedure, she had an anaphylactic reaction to the cystic fluid, which required ICU management. She recovered in a few days and was treated pharmacologically with two doses of albendazole. PAIR was then performed on liver lesions. Though she tolerated this procedure well, she continued to have intermittent fevers with leukocytosis and significant eosinophilia. Initial plan was to complete 3–6 months of albendazole, however, due to her persistent fevers, she was given 4 weeks of praziquantel, in addition to albendazole.

This case is of interest due to her rare presentation with both liver and lung cysts. According to UptoDate, 90% of cases consist of single organ involvement, and in 70% of cases only 1 cyst is identified. Further case reports on this disease could lead to more management options in multiple organ involvement. Furthermore, this case also allows us to consider ways pediatricians could conduct more routine travel screening and prophylaxis, including anticipatory guidance on appropriate travel practices.

16 A case of mycoplasma-associated Anti-N-Methyl-D-Aspartate receptor encephalitis

E Larsen1*

R Thukaram2

1Saint Francis Children’s Hospital, Tulsa, OK

2University of Oklahoma School of Community Medicine, Tulsa, OK

Introduction

Pediatric encephalitis is challenging to evaluate and treat given the variability of presentation. An etiology is identified in less than 50% of cases. Many studies reveal Mycoplasma pneumoniae as a common infectious agent. Anti-N-Methyl-D-Aspartate receptor (ANMDAR) encephalitis is an autoimmune condition that often manifests as a paraneoplastic phenomenon. However, the majority of affected pediatric patients do not have an associated neoplastic antigenic stimulus. There have been few documented cases of ANMDAR+ patients with serologic evidence of Mycoplasma infection. Here we present a 2-year-old with ANMDAR encephalitis secondary to M. pneumoniae.

Case Presentation

A previously healthy 2-year-old female presented to the PICU with altered mental status, choreoathetoid and repetitive orofacial movements. Comprehensive autoimmune work-up was pending when M. pneumoniae serum IgM antibody was confirmed. MRI of brain and spine were normal with no demyelinating lesions. With concern for Mycoplasma-associated encephalitis, high dose corticosteroids, IVIG, and plasmapheresis were initiated. Her dyskinesia and dysautonomia persisted, requiring multiple psychotropic medications. Once ANMDAR antibodies were detected in the cerebral spinal fluid, second line therapy with weekly rituximab, biweekly IVIG, and high dose corticosteroids were initiated. CT abdomen and pelvis revealed no evidence of tumor. Clinical improvement may take up to 2 years following aggressive immunomodulating therapies. Our patient remains in critical condition and continues to be closely monitored for improvement.

Conclusion

The recognition of M. pneumoniae and ANMDAR encephalitides as common causes of infectious and autoimmune encephalitis respectively, underscores the need for ongoing surveillance for Mycoplasma as an antigenic trigger for ANMDAR encephalitis. Mycoplasma is ubiquitous, making it challenging to identify it as a causative agent. The possibility of concomitant infectious and autoimmune encephalitis suggests that an infectious agent should not be accepted as the sole explanation. Strong consideration for an autoimmune etiology, even at initial presentation, will lead to early diagnosis, early treatment, and optimistically, better neurologic outcomes.

17 Don’t be salty, it’s just a UTI

E Mertens*

C Irwin

E Dobish

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Case Report

A 12 year old male with 13q deletion, deafness, blindness, gastrostomy tube dependence, and ambiguous genitalia was admitted with hyponatremia. He presented to his primary care physician with irritability; labs showed sodium of 119 and he was sent to an outside facility. There, sodium was 124 and potassium was 6.2, prompting transfer to our facility. Mother noted the patient had been afebrile but had malodorous urine for several days prior to admission. One year prior, he had an episode of hyponatremia and urinary tract infection (UTI). He saw endocrinology and nephrology and was reportedly diagnosed with hypoaldosteronism, but per mother, has had normal electrolytes without any medication or supplementation.

Patient was alert, nonverbal, and irritable but consolable. He had dysmorphic facies with a broad, flat forehead and depressed nasal bridge. He was tachycardic with regular rhythm and 2/6 systolic murmur at the left upper sternal border without radiation. The remainder of exam was normal.

Admission labs showed sodium 124 and potassium 6.9 (non-hemolyzed). IV normal saline was started with q6h electrolytes. He was initially afebrile but developed fever to 39.6°C on day two. Urinalysis and urine culture showed E. coli UTI. Ceftriaxone was started. Nephrology and endocrinology were consulted and recommended renin and aldosterone levels (both elevated), cortisol level (normal), and urine electrolytes, which showed a transtubular potassium gradient of 3.7, consistent with hypoaldosteronism. After 3 days of ceftriaxone, electrolytes normalized, fever curve improved, and he was tolerating feeds. Labs 6 weeks later showed normal serum sodium, potassium, renin, and aldosterone.

This patient was ultimately diagnosed with transient pseudohypoaldosteronism due to a UTI. Literature review showed multiple reports of a transient aldosterone-resistant state in infants with culture-confirmed UTI, many with co-existing structural renal disease. These patients presented with similar hormone and electrolyte abnormalities that resolved after antibiotic treatment, paralleling our patient’s course. Interestingly, the UTI was not immediately apparent in this case, given absence of fever and inability to communicate pain or discomfort, and it was discovered only after further history and workup.

18 Multisystem inflammatory syndrome in children presenting as acute acalculous cholecystitis

AM Larsen1*

KS Baab2

L Bode3

RP Barton4

K Martin1

1The University of Oklahoma School of Community Medicine, Tulsa, OK

2OU School of Community Medicine, Tulsa, OK

3Oklahoma State University Center for Health Sciences, Tulsa, OK

4The Children’s Hospital at Saint Francis, Tulsa, OK

Case Report

Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare, hyperinflammatory complication of SARS-CoV-2 infection. The diagnostic criteria established by the CDC require fever, laboratory evidence of inflammation, clinically severe illness requiring hospitalization with multisystem organ involvement, and evidence of current or recent SARS-CoV-2 infection.

Case Description

A previously healthy eight-year-old male without clinical history of SARS-CoV-2 infection presented to the pediatric emergency department with a three-day history of fever and abdominal pain and was found to have acute acalculous cholecystitis. He quickly developed hyperinflammatory shock and had positive SARS-CoV-2 serology. Following treatment with intravenous immunoglobulin (IVIG) and high dose corticosteroids, his fever and shock quickly resolved. Acalculous cholecystitis resolved within two weeks of IVIG.

Discussion

Presentations of MIS-C vary significantly and some documented cases more closely resemble severe COVID-19 or Kawasaki Disease vasculitis. This case is clinically and phenotypically distinct and represents the newly recognized hyperinflammatory physiology unique to MIS-C. It is important for pediatric clinicians who encounter any inflammatory disease process, including acalculous cholecystitis, to include MIS-C in the differential diagnosis.

Cardiovascular club

11:00 AM

Thursday, February 25, 2021

19 Reversion-inducing cysteine-rich protein with kazal motifs positively regulates macrophage efferocytosis

Y Higashi1*

S Danchuk1

P Delafontaine1

C Bysani2

1Tulane University School of Medicine, New Orleans, LA

2University of Missouri School of Medicine, Columbia, MO

Purpose of Study

Efferocytosis is a process by which apoptotic cells are cleared by phagocytotic cells. Defective efferocytosis causes tissue necrosis leading to sterile inflammation, resulting in chronic inflammatory diseases, including atherosclerosis. In atherosclerosis, it is suggested that proteolytic cleavage of transmembrane receptor tyrosine kinases, such as MERTK (MER Proto-oncogene, Tyrosine Kinase), causes defective efferocytosis and promotes plaque progression. Reversion inducing cysteine rich protein with Kazal motifs (RECK) is an inhibitor of matrix metalloproteinases, whose role in macrophage efferocytosis is unknown. Further, we investigated the role of ADAM17, a member of the ADAM (a disintegrin and metalloprotease domain) family of metalloproteinases, in MERTK shedding.

Methods Used

Bone marrow-derived macrophages were prepared from myeloid-specific RECK-conditional transgenic mouse. MERTK mRNA and protein expression levels were assessed by RT-qPCR and western blotting. ADAM17 activity was assessed using fluorogenic ADAM17 substrate, Dabcyl-PRAAAHomopheTSPK(5FAM)-NH2. Efferocytosis activity was assessed using apoptotic Jurkat T cells as a bait.

Summary of Results

Macrophages with RECK overexpression had elevated levels of MERTK protein, but not mRNA, compared to wild-type cells, suggesting posttranscriptional upregulation. Interestingly, ADAM17 activity was lower in RECK-overexpressing macrophages by a significant 34% (P<0.05) vs. wild-type cells. In accordance with the elevated levels of MERTK, RECK overexpressing macrophages demonstrated higher efferocytosis activity by a significant 117% (P<0.05) compared to wild-type cells.

Conclusions

Myeloid-specific RECK overexpression elevates MERTK protein levels, at least in part via ADAM17 inhibition, and promotes macrophage efferocytosis activity. Our findings suggest that RECK is a novel mediator of efferocytosis and has the potential to attenuate tissue necrosis and inflammation in atherosclerotic plaques.

20 CRISPR/CAS9 gene editing applications in cardiovascular disease

J Khouzam1*

R Khouzam2

V Tivakaran3

1University of Notre Dame College of Science, Dayton, OH

2The University of Tennessee Medical Center, Knoxville, TN

3Kettering Health Network, Dayton, OH

Purpose of Study

The purpose of this review article is to investigate the current applications of the CRISPR/Cas-9 gene editing system through the lens of cardiovascular disease and examine potential untouched applications of the system in the field of cardiology. Since its fairly recent discovery, CRISPR/Cas-9 system’s efficiency and simplicity have been successfully used to edit genomes of living organisms in many fields, working in vitro and in vivo in germline and somatic cells to knock-out harmful mutated genes or in some cases working to knock-in a beneficial gene. A current application of the gene-editing system works against mutations in cardiovascular cells that induce types of cardiovascular disease.

Methods Used

Genome-editing techniques have been applied to developing embryos and adult organisms to produce loss-of-function mutations to deleterious genes and gain-of-function mutations to restore function of a protein in the cell. The CRISPR-Cas9 system is most often used in vitro, delivered to cells through traditional methods of electroporation or microinjection. Most in vivo studies use viral vectors such as adeno-associated viruses and adenoviruses (AAV and AdV) and lentiviral vectors (LV) in rodents. The nature of most genome-editing technologies gives them potential to be effective in treating diseases that are caused by a single gene for which other medical treatments have been largely ineffective.

Summary of Results

Researchers successfully identified cardiovascular disease causing genes for coronary heart disease, hypertrophic cardiomyopathy, WPW syndrome, and long QT syndrome. Using CRISPR/Cas9, these research studies successfully used CRISPR/Cas9 gene editing in vivo and in vitro to rid an organism or cell of the disease causing mutation. The in vivo studies also showed decrease in symptoms of these diseases as well as an avoidance of off target effects and mosaicism.

Conclusions

Overall, the CRISPR/Cas9 system shows promise in completely revolutionizing treatment of cardiovascular diseases and many other diseases. Current research offers potentially effective treatments using somatic and germline editing of disease-causing genes, however, clinical research does not go beyond applications in vitro and in small animal models.

21 The clinical role of superconduction and entanglement with the quantum state in paired isolated heart myocites-related to heart function

PI Altieri1,2*

W De Mello1

N Escobales1

HL Banchs1,2

1University of Puerto Rico Medical Sciences Campus, San Juan

2Cardiovascular Center of Puerto Rico and the Caribbean, San Juan, Puerto Rico

Purpose of Study

Superconductivity (S.C.) is a concept of pushing materials to the extremes to get maximum results of the processes. The purpose of this study is to study the role of superconduction and entanglement in paired isolated heart myocites, especially in left heart function (L.V.F.).

Methods Used

Applying superconductivity concepts experiments were done intracellularly in isolated heart cell pairs measuring intracellular electric conduction across junction gaps (G.I.) induced by Enalapril (E.) and Angiotensin II (Ang II). E. (25 ug/ml) was injected rapidly up to a dose of 1 ug/ml in 4 minutes. A plateau was reached at a value of 106% from the base. Ang II was injected at 1 ug/min with a reduction of G.I. (55%) without a plateau.

Summary of Results

We think the reason for the plateau was a reduction of entanglement with E., but not with Ang II in a superconductivity state due to a photon effect from an intracellular electron cloud. The effect of E. is more effective in the coupling of the heart myocites than Ang II which reduces coupling of myocardial cells, as shown in our experiments. This is a very important electrical effect (coupling) in congestive heart failure (C.H.F) with improvement of left ventricular function L.V.F. by E. and a reduction of coupling and L.V.F. by Ang II.

Conclusions

Further studies are needed to clarify these concepts in hemodynamics of L.V.F. and the role of Quantum state in these hemodynamics changes and the importance of both drugs in modifying L.V.F. and C.H.F. through coupling and uncoupling of myocites.

22 Macrophage specific igf-1 downregulates CXCL12 chemokine and decreases atherosclerotic burden in apoe-null mice

P Snarski1*

S Sukhanov1

T Yoshida1

Y Higashi1

S Danchuk1

S Shai1

C Bysani2

P Delafontaine1

1Tulane University, New Orleans, LA

2University of Missouri School of Medicine, Columbia, MO

Purpose of Study

Insulin Like Growth Factor (IGF-1) has potent mitogenic and pro-survival effects. We have shown that systemic IGF-1 administration reduced atherosclerosis in ApoE deficient (Apoe-null) mice fed a high fat diet and that those animals have reduced plaque macrophages. We have shown that IGF-1 is atheroprotective, but exact mechanisms still need to be identified. IGF-1 can act on all three major cell types in atherosclerotic plaque: macrophages, smooth muscle cells, and endothelial cells, and previous data shows a large effect on macrophages. We hypothesized that increasing IGF-1 levels strictly in macrophages will prevent atherosclerosis.

Methods Used

Using a novel macrophage-specific IGF-1 overexpressing transgenic mice on an Apoe-null background (MF-IGF1 mice), we assessed atherosclerotic plaque burden, stability, and monocyte recruitment. We isolated plaque using laser capture microdissection and we analyzed monocyte recruitment via intravenous injection of fluorescent red beads among other traditional techniques.

Summary of Results

Macrophage IGF-1 downregulated plaque burden by 30% (P<0.01), reduced plaque macrophages by 47% (P<0.001), and increased features of plaque stability. Monocyte recruitment was reduced by 70% (P<0.05) in MF-IGF1 mice and was associated with a decrease in circulating levels of CXC Chemokine Ligand 12 (CXCL12) (27% reduction to control, P<0.05). CXCL12 protein levels were reduced in plaque and peritoneal macrophages in MF-IGF1 mice. IGF-1 completely blocked oxLDL-dependent increase of CXCL12 mRNA transcription (98% reduction to control, P<0.01) and IGF-1 treatment reduced CXCL12 protein (56% decrease to control, P<0.001) in vitro.

Conclusions

Overall, our results indicate that macrophage IGF-1 reduces atherosclerosis and reduces CXCL12, a chemokine newly implicated in atheroprogression. IGF-1 potentially exerts its atheroprotective effect via this reduction in CXCL12.

23 Impact of obesity on patients with adult congenital heart disease

PP Boddie*

MR McMullan

University of Mississippi Medical Center, University of Mississippi Medical Center, Jackson, MS, US, academic/hospital, Jackson, MS

Purpose of Study

Mississippi is a unique population in that it is among the states with the highest rates of obesity and cardiovascular comorbidities. Studies have suggested that risk factors for cardiovascular disease are associated with high mortality in patients with adult congenital heart disease (ACHD). Our retrospective cohort study will investigate obesity and the correlation between mortality and comorbidities such as hypertension (HTN), hyperlipidemia (HLD), and type II diabetes mellitus (T2DM) in Mississippi’s ACHD population. Findings may be applied towards management of Mississippi’s ACHD population.

Methods Used

Cohorts were generated using Qlikview Patient Cohort Explorer application. Subjects included were over 18 with a diagnosis of congenital heart disease. Searches were conducted inclusive of years 2013-present. Information regarding obesity and HTN, HLD, and T2DM was investigated. Obesity data was compared to a New York study. Mortality rate for each comorbidity was determined and compared to Mississippi’s general population.

Summary of Results

Our findings have shown that Mississippi’s ACHD population suffers from a higher prevalence of obesity when compared to reference ACHD population (39% MS vs 25.6% NY). We have also seen a higher prevalence of HTN, HLD, and T2DM among our ACHD patients than our general population. Mortality rates of ACHD subjects with these comorbidities was found to be higher than our general population (see table 1).

Abstract 23 Table 1

Mortality rates by comorbidity

Conclusions

Thus far, our findings show that Mississippi’s ACHD population is unique in that it faces high rates of obesity and that the presence of HTN, HLD, and T2DM correlate with poor outcomes. These findings emphasize the importance of preventive measures when treating ACHD patients with regards to minimizing cardiovascular risks.

24 At the heart of the game: are die-hard sports fans at risk of cardiac events?

M Maturana1*

EA Glover1

J Raja1

S Dornbush1

J Alexander1

C Blount

N Khouzam3

A Khouzam3

RN Khouzam1,2

1University of Tennessee Health Science Center, Memphis, TN

2The University of Tennessee Health Science Center, Memphis, TN

3Christian Brothers High School, Memphis, TN

Purpose of Study

This abstract aims to review the current understanding of the risk of cardiac events in die-hard sports fans as spectators of major sporting events.

Methods Used

Our review article contains a Medline search of studies published prior to July 20, 2020 identified with the following key words: ‘sports fans’, ‘spectators’, ‘sporting events’, and ‘cardiovascular risk’. Most literature to date centers around soccer, baseball, football and rugby spectatorship. We examined these pivotal studies to compare the effects of spectatorship and its relationship with cardiovascular health.

Summary of Results

Multiple studies have shown that intense emotions and psychological stress have been associated with myocardial infarction, symptomatic arrhythmias, and sudden cardiac death. Similarly, die-hard soccer, rugby, football, and baseball fans seem to be at risk of cardiac events, particularly if a prior history of coronary artery disease is present (table 1).

Abstract 24 Table 1

Cardiovascular events in sports fans

Conclusions

Several studies have found an increased number of arrhythmogenic events including fatal arrhythmias, chest pain, unstable angina, acute coronary syndrome, and sudden cardiac death in patients who are sport spectators. High risk behaviors like tobacco use and binge drinking appear to contribute to this risk, generating a pro-inflammatory state characterized by elevated levels of endothelin-1 and overexpression of sCD40L, sVCAM-1, MCP-1, and TNF-alpha. The outcome of the game and unexpected endings both seem to further promote negative cardiovascular outcomes.

Moving your clinical case presentation into a published manuscript

11:00 AM

Thursday, February 25, 2021

25 Multisystem inflammatory syndrome in children or incomplete Kawasaki?

RA Salazar*

RD Smalligan

S Battle

UAB-Huntsville, Huntsville, AL

Case Report

A 2yo girl presented with 7 days of fever as high as 103F. 5 days prior she was dx’d with OM and given amoxicillin, but fevers persisted. On day of presentation she had a new rash and eye redness without discharge. Prior to the illness she was exposed to her MGM who tested positive for COVID-19. Mom works as a nurse who interacts with COVID patients but was asymptomatic. PE: fussy but non-toxic appearing, T 98.1, HR 132, RR 38, BP 102/60 and O2 98% RA, HEENT: dry, cracked lips, injected conjunctivae, no cervical lymphadenopathy, lungs clear, heart RRR without murmurs, no hand or foot swelling but there was a desquamating rash on both LE. Labs: CRP 5.2, ESR >80, ferritin 66, Pro-BNP 182, WBC 14k, lymphs 15%, platelets of 677k. Patient was diagnosed with incomplete Kawasaki disease (IKD) with suspicion for COVID related MIS-C. She was treated with IVIG and aspirin. She started showing improvement and was discharged a couple of days later. Follow up echo showed slight dilatation of one coronary artery. Her COVID-19 test came back negative.

Discussion

In 2020, with COVID-19 spreading across the world, IKD and MIS-C can be challenging to differentiate. Patients with IKD must have fever for at least 5 days while only 24 hours are required to be diagnosed with MIS-C. IKD patients must have 2–3 of the following 5 findings: bilateral conjunctival injection, changes in lips and oral cavity, cervical lymphadenopathy, swelling of the hands or feet and a polymorphous rash. IKD also requires positive coronary artery dilation on echocardiogram or elevated inflammatory lab values. Some MIS-C patients look very similar to IKD with a desquamating rash, mucous membrane involvement, and increased inflammatory markers. Even coronary artery dilation and aneurysms have been seen in MIS-C.

MIS-C patients are generally older (2–15yo), compared to those with IKD (1–4yo). MIS-C patients may have respiratory distress, vomiting and diarrhea or neurologic symptoms like headache and encephalopathy. They can also present with shock or an acute abdomen, which is uncommon in IKD. MIS-C patients tend to have far higher levels of Pro-BNP, CRP and D-Dimer compared to IKD. In the end, IKD and MIS-C can both be successfully treated with IVIG which makes the need to accurately differentiate between the two diseases less urgent.

26 A unique presentation of guillain-barre syndrome as a post-infectious complication of covid-19

G Willhelm1*

E Alshaikh2

P Yedla2

1The University of Alabama at Birmingham School of Medicine, Gurley, AL

2The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

Case Report

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel respiratory pathogen, the complications and sequelae of which are still being established. Guillian-Barre syndrome (GBS) is an acute immune-mediated disease of the peripheral nervous system which has been associated with gastrointestinal and respiratory tract infections. GBS is now being reported as a rare neurological complication of severe COVID 19 infection.

In this clinical case report, we highlight an unusual case of GBS following a mild SARS-CoV-2 infection. A 65-year-old male presented to our emergency department (ED) with a 1 week history of lower extremities weakness, difficulty ambulating and paresthesia of the distal extremities. During his most recent visit to another ED, patient was diagnosed with vitamin D deficiency and sent home. Rapid worsening of symptoms prompted his presentation to the hospital. The patient had been diagnosed with COVID-19 approximately 3 weeks prior to presentation with fevers, chills, and muscle cramps treated with IV fluids. On examination, patient had an ataxic gait with diffuse areflexia in all extremities. MRI brain and spine showed no acute abnormalities. Cerebrospinal fluid analysis (CSF) was notable for albumin cytologic dissociation. Based on the clinical presentation and CSF analysis, the patient was diagnosed with GBS most likely as a post-infectious immune-mediated complication of COVID-19. Cause was established due to lack of other possible inciting factors, such as neurotoxic agents, viral illnesses, or vaccinations. CSF PCR for SARS-CoV-2 was not performed due to almost universally negative results in prior case reports. During the hospital course, patient was treated with a 5-day course of intravenous immunoglobulin and methylprednisolone, resulting in moderate improvement of symptoms. Patient was able to walk on Day 3 of treatment. This case highlights the importance of prompt recognition and treatment of an unusual presentation of GBS in the setting of recent mild SARS-CoV-2 infection.

Adolescent medicine and pediatrics

1:00 PM

Thursday, February 25, 2021

27 Social media and gaming use negatively impacts youth school performance

A Yoders*

SA Ray

D Wood

M Quinn

K Phalen

East Tennessee State University, Johnson City, TN

Purpose of Study

Excessive video game and social media use has the potential to negatively affect youth academic performance, but a limited number of studies have comprehensively evaluated this relationship. The objective of this study was to examine the relationship between youth social media and gaming (SM/G) habits and school performance.

Methods Used

Using a convenience sample of adolescents (ages 12–17), a self-administered, confidential survey was fielded in two clinical centers. This report is on the first 145 patients enrolled from the ETSU Adolescent/Young Adult/Transition Clinic. This study is on-going and data will be reported on a larger sample in the future. SM/G use patterns were assessed using questions adapted from the Common Sense Media national survey. Youth were asked to report hours spent daily on SM/G and to rate whether their SM/G negatively affected their homework or grades (scale: Never, Rarely, Sometimes or Often). Scales were re-coded to ‘never’ or ‘any’ for analysis of SM/G effects on homework or gaming. Bivariate and multivariate analyses were used to determine important associations.

Summary of Results

Of the 145 respondents, the mean age of the sample was 14.9 (SD = 1.4) with 51.7% identifying as female. Over a quarter of the sample reported spending 5 or more hours gaming per day (27.6%), while 37.1% reported using social media for 5 or more hours per day. 33.8% of youth reported that gaming negatively affected their grades and 42.8% reported that it impaired their ability to complete homework; 27.6% of youth reported that their social media use negatively affected their grades and 44.1% reported that it impaired their ability to complete homework. Males were much more likely to report that gaming affects their grades (OR = 2.2, CI: 1.06–4.44, p = 0.033) or homework (OR = 2.5, CI: 1.26–4.97, p = 0.009).

Conclusions

A large proportion of both males and females report high use of social media and gaming, to the extent that it affects their school grades and their ability to complete homework. However, males were much more likely to be negatively affected by excess gaming.

28 Promoting literacy among infants 0–6 months in primary care clinics

S Rolader*

A Caldwell

M Dunlap

C Garbe

Oklahoma University Health and Sciences Center, Oklahoma City, OK

Purpose of Study

Pediatricians have a unique opportunity to help families during early childhood to improve language development and promote literacy. Reach Out and Read (ROR) is a program that promotes early language skills and literacy. Utilizing ROR at well child visits (WCV) for infants less than six months has not been well studied. This study evaluated literacy promotion practices for infants under 6 months of age among pediatric faculty and residents at two pediatric practices.

Methods Used

Parents who presented for their child’s WCV at 2 weeks, 2 months, and 4 months were surveyed by an anonymous paper survey to see what literacy based guidance was provided. Pediatric residents and faculty members were sent an anonymous electronic survey to assess literacy promotion behaviors and perceptions among infants under 6 months. Descriptive statistics were used for each survey question and differences in responses between residents and faculty were analyzed using chi square tests.

Summary of Results

Seventy-four parent surveys were completed. During their clinic visit, 43% of parents reported their provider discussed reading, 42% the benefit of reading aloud, 38% how to read with your child, and 57% the importance of talking to your child. Close to 90% of residents and faculty reported it is the job of pediatricians to assess and encourage reading among infants under 6 months, and nearly 100% reported it is the job of pediatricians to assess and encourage caregivers to talk to infants under 6 months. All faculty either agreed/completely agreed that they felt adequately trained to speak with caregivers about reading and talking to children 0–4 months of age while only 64% of residents did (p=0.002). Most faculty (93%) reported comfort in discussing reading with parents of young infants compared to 85% of residents (p=0.04).

Conclusions

While the clinics studied did not formally include infants under 6 months in their ROR program, providers are providing guidance to many of these families in accordance with the AAP national guidelines. There is a need for literacy promotion training for young infants, especially among pediatric residents and this could result in improved literacy outcomes for children.

29 Evaluation of a standardized pathway for treatment of patients with diabetic ketoacidosis in a pediatric emergency department

NP Shah*

C Campbell

P Garlington

J Atchison

L Nassetta

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

We implemented a standardized care pathway for patients with Diabetic Ketoacidosis (DKA) in the Emergency Department (ED) of our freestanding children’s hospital. We sought to determine the impact of the pathway on the time to resolution of acidosis.

Methods Used

This retrospective study included children 24 months through 17 years with DKA treated in our ED. We compare outcomes for patients 2 years prior (pre-group) and 2 years following (post-group) pathway implementation in May 2015. Patients were identified in our EHR using ICD-9 & 10 codes for DKA. Resolution of acidosis was defined as serum bicarbonate (HCO3) > 15 mmol/L or anion gap ≤ 15 mmol/L. Data collected included demographics, initial serum HCO3 level and anion gap, times when initial serum HCO3 and anion gap were recorded, and times when serum HCO3 > 15 mmol/L and anion gap ≤ 15 mmol/L. Descriptive statistics were performed for frequencies and proportions, median [interquartile range (IQR)], and Mann-Whitney U test was used to compare the time to resolution of acidosis between pre- and post- implementation groups.

Summary of Results

We evaluated 500 cases of DKA, with 250 in each group. The pre-group was 40% male; median age 12 years (IQR 10–15); and 52% white. The post-group was 44% male; median age 13 years (IQR 10–15); and 67% white. The median initial serum HCO3 was 9.1 mmol/L (IQR 6.6–12) in pre-group compared to 9.9 mmol/L (IQR 7 -12.7) in post-group. Median initial anion gap was 26 mmol/L (IQR 23–31) in both groups. The median time to normalization of serum HCO3 was 9 hours (IQR 6–12) in pre-group and 8 hours (IQR 6–13) in post-group (p = 0.74). The median time to normalization of anion gap was 7 hours (IQR 5–10) in pre-group and 7 hours (IQR 6–10) in post-group (p = 0.64).

Conclusions

While implementation of a standardized pathway for the treatment of DKA patients led to faster resolution of acidosis, this was not statistically significant. Further studies should evaluate elements of a DKA pathway that may be associated with improved outcomes.

30 Pediatric firearm injury in MS

LW Benton1*

E Landry2

C Henderson2

1University of Mississippi School of Medicine, Jackson, MS

2University of Mississippi Medical Center, Jackson, MS

Purpose of Study

To evaluate and describe firearm-related injuries in Mississippi children from 2012–2019.

Methods Used

Using the Mississippi (MS) Trauma Registry, we identified patients aged 0–15 years who sustained a firearm-related injury from 2012–2019. For the purpose of this study, a firearm is any weapon utilizing explosive propellant. A retrospective chart review to verify data was performed on patients treated at University of MS Medical Center (UMMC), the only pediatric trauma center in MS. Data included demographics, injury details (fatal, self-inflicted, accidental/assault, weapon, etc.), Trauma Injury Severity Score (TRISS), medical care (surgeries, ICU care, length of stay, etc.), and location where injury occurred. Data was maintained in RedCap, a secure web-based platform. Preliminary data analysis is described.

Summary of Results

We received 403 patients; 183 were determined to have a firearm-related injury. Of those, 53% were assault or suicide attempt; 42% were accidental. Only 20% were self-inflicted. Majority were male (76%) and African American (74.9%). Most (72%) involved the use of a handgun/pistol. Half (51%) required surgery, and a third (34%) required ICU care. Based on the TRISS, the cohort’s average probability of survival was 89%. Only 11% were fatal; our dataset did not include children who died at the scene and did not receive medical care. Over the time period studied, we found a trend toward an increasing number of firearm-related injuries in MS children each year. One third of injuries occurred within the Jackson Metro area; the remainder were in surrounding counties.

Conclusions

Firearm injuries in children can lead to significant injury and morbidity. Our study sought to describe the impact of firearm injuries on MS children. The preliminary data included here begins to illustrate the burden of care related to firearm injuries; further statistical analysis will be conducted and may reveal important information about hospital cost, long term morbidity, and specific populations at risk. MS leads the nation in gun violence and our study shows an increasing trend in firearm injuries annually as well. Data about hospital utilization, cost, and geographic ‘hot spots’ for firearm violence may lend to effective changes in community engagement and legislative policy toward lowering rates.

31 Trends and demographics of pediatric firearm injuries from 2000–2019

E Jorge*

NP Shah

A Haque

D Atherton

R Russell

K Monroe

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

Firearm-related injuries are the second leading cause of pediatric death in the US. The aim of this study was to analyze trends of pediatric firearm injuries & deaths in a high-risk southern state and identify the populations at most risk.

Methods Used

A retrospective chart review of 1) firearm-related hospitalizations at the state’s only freestanding children’s hospital and 2) the local county medical examiner’s office records of firearm-related deaths was conducted from 2000–2019. Data collected included basic demographics, year of injury, intentional/unintentional injury, shooter age, circumstances of incident, and clinical outcome. Descriptive statistics were performed for frequencies, proportions, and median [interquartile range (IQR).

Summary of Results

540 patients were enrolled in the study (76% from hospital records, 24% from medical examiner’s records). The annual number of firearm-related injuries & deaths rose by nearly 176% (2.76x) from 2000 to 2020. Ages of victims ranged from 1 month to 19 years (median 14, IQR 9–16). Males accounted for 3 out of every 4 victims (76%). African Americans were the most affected ethnicity (71%). Intentional injuries (53%) were more common than unintentional injuries (35%), but unintentional injuries increased at a faster rate over time. 1 out of every 4 children were injured while playing with a firearm. The age of the shooter ranged from 1- 47 years (median 14, IQR 9–17). Death (31%) was the most common outcome and 13% had long-term disability.

Conclusions

In a state with high firearm ownership and death rates, annual pediatric firearm injuries and deaths rose by nearly 3 times in 20 years. Firearm injuries affected a wide range of ages and have high mortality. African Americans, males, and children > 12 years of age were disproportionally affected. With unintentional injuries on the rise, pediatricians need to counsel families on the importance of safe firearm storage.

32 Intranasal versus intravenous ketamine for procedural sedation in children with non-operative fractures

J Statler1*

NP Shah1

HH Cunningham2

ER Kaplan2

C Vong do Rosario2

J Barber1

1University of Alabama, Birmingham, AL

2University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

Children who come to the emergency department (ED) with fractures often require sedation and analgesia for reduction. Evidence demonstrates intranasal (IN) analgesics provide a rapid and effective means of pain control. When these injuries call for closed reduction, IVs are used for procedural sedation and analgesia (PSA). If adequate PSA could be achieved via the IN route, this could forgo the need for IV. There is evidence to suggest a role for IN Ketamine for PSA. A pilot study suggested 9 mg/kg IN ketamine for PSA during laceration repairs. The efficacy of IN ketamine for PSA has never been studied head-to-head with comparators such as IV ketamine.

Methods Used

This is a prospective, randomized controlled, non-inferiority trial of children ≤ 25 kg with non-operative fractures undergoing closed reduction. Patients will be randomized to 1 of 2 groups to receive 9 mg/kg IN ketamine or 1.5 mg/kg IV ketamine. To ensure blinding, all subjects will have IV access and first receive IN medication [ketamine or hypertonic saline (3%)] followed by IV medication (normal saline (NS) or ketamine, respectively). Adequate sedation will be determined by a modified Ramsay sedation score of ≥ 4. Scores will be assigned every 5-minutes. Sedation failure will be defined by a score < 4 after 10 minutes; in these cases, patients will receive 0.5 mg/kg IV ketamine or more as deemed necessary by ED physician to complete reduction.

Summary of Results

This study is currently in the enrollment process. The primary outcome is the proportion of successful sedations between the two study groups. With a non-inferiority margin of 10%, one-sided alpha of 0.025, and power of 90%, we anticipate a sample size of 70 participants to detect PSA completion comparison of no greater than a 2% difference in proportion of successful sedation between groups. Categorical and continuous variables will be analyzed using statistical tests with 95% confidence intervals.

Conclusions

The aim of this study is to investigate whether IN ketamine is both feasible and efficacious for PSA, compared to IV ketamine, during closed reduction of isolated non-operative fractures.

Case reports in cardiovascular medicine

1:00 PM

Thursday, February 25, 2021

33 An unexplainable case of cardiomyopathy after covid like symptoms

P Sobash*

S Wang

C Jeukeng

K Vedala

R Kamoga

White River Medical Center, Batesville, AR

Case Report

The most common cause of congestive heart failure is ischemic cardiomyopathy. Workup of new onset CHF consists of laboratory values, physical exam, symptoms, echocardiogram and potentially a left heart cath. When readily apparent causes are absent, careful history can help determine an underlying etiology. We present the case of a 49-year-old African American female with newly diagnosed CHFrEF who presented with complaints of increasing SOB and significant weight gain over the past few months. Patient has a smoking history, asthma and non-convulsive seizures. Her only home medications are inhalers. She states that back in February of 2020, she had COVID like symptoms, including fevers, chills, and episodes of delirium. She never underwent diagnostic testing, but self-quarantined for 2 weeks with mild improvement. Since that time, she has had respiratory issues that have not resolved. In June, she was seen at our center for a cholecystectomy and ventral hernia repair with subsequent orthopnea, PND’s, and worsening lower extremity swelling edema with 50 lb weight gain. Laboratory values on admission showed proteinuria, slight hyponatremia at 134 mmol/L, BNP of 6220 pg/ml, Hgb A1c of 6.3%, and slight elevation of AST and ALT at 59 U/L and 36 U/L respectively. Workup for other endocrinological abnormalities was negative. Echo revealed EF of <20% and she was started on appropriate therapy with some resolution of symptoms while inpatient. A left heart catheterization revealed no ischemia, prompting the question of why she developed such pronounced heart failure at age 49 with few risk factors. We were unable to obtain a biopsy of the heart to assess for viral myocarditis. While the pathophysiology of COVID induced cardiomyopathy is still unclear, it is thought to be due to a cytokine storm resulting in organ damage. With no other seemingly identifiable cause, even with a negative IgG test, we suspect that her heart failure is secondary to recent COVID infection. The teaching point of our case is when there is heart failure failure suspected to be secondary to myocarditis, especially with a history of suspected or confirmed COVID, then further workup with heart biopsy or MRI should be performed to look for myocarditis to help confirm diagnosis.

34 Chronic thromboembolic pulmonary hypertension in the setting of essential thrombocythemia

MB Lewis*

D Busby

J Blossom

C Moore

D Clark

University of Mississippi Medical Center, Jackson, MS

Case Report

Group IV Pulmonary Hypertension refers to thromboembolic obstruction of the pulmonary arteries which can lead to right heart failure and death without early diagnosis and intervention. Here, we report a case of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) with right ventricular failure in the setting of Essential Thrombocythemia (ET).

A 36 year old African-American female with asthma presented with difficulty breathing. She reported worsening of symptoms over 1 year. Physical exam was remarkable for pitting lower extremity edema to bilateral mid-thighs and jugular venous distension. Labs were notable for platelets 620,000/UL, pro-BNP 2268 pg/mL, and D-dimer 1307 ng/mL. Transthoracic echocardiogram showed a dilated main pulmonary artery, enlarged right ventricle (RV), and dilated right atrium. Estimated RV systolic pressure was 65 mmHg, and left ventricular ejection fraction was 60%. Computed tomography revealed acute and chronic bilateral pulmonary emboli, interventricular septal flattening, and a 1.8 centimeter RV thrombus. She was started on warfarin with heparin bridge. Right heart failure was treated with digoxin and furosemide which alleviated symptoms of dyspnea. She later tested positive for JAK2 V617F mutation, leading to a diagnosis of ET. Hydroxyurea therapy was initiated. Currently, she is being evaluated for surgical management with pulmonary thromboendarterectomy.

CTEPH is a rare cause of pulmonary hypertension with associated high morbidity and mortality. Those with chronic myeloproliferative diseases (CMPD) like ET are at increased risk of thrombosis which can lead to CTEPH. Early detection and intervention are crucial since patients can be cured surgically. Identifying CMPD is necessary, as these disorders allow for alternative treatment options. A high level of suspicion is important, as 25% of patients have no history of thromboembolic event. This case demonstrates that CTEPH should be considered in patients with unexplained exertional dyspnea with or without prior history of a thromboembolic event.

35 A case of refractory cardiogenic shock caused by zinc phosphide toxicity

M Abohelwa*

J Abdelmalek

T Dixon

G Del Rio-Pertuz

E Elgwairi

K Nugent

Texas Tech University System, Lubbock, TX

Introduction

Zinc Phosphide is a highly toxic rodenticide and is used worldwide to protect grains from rodents. Upon ingestion, Zinc phosphide is converted by gastric acid into Phosphine gas, which get absorbed very quickly into the bloodstream. It inhibits the oxidative phosphorylation within a few hours, causing myocardial stunning. Death usually occurs from cardiac arrhythmias and refractory cardiogenic shock.

Case presentation

A 20-year-old male patient, known to have bipolar disorder, presented to the ED after ingesting a zinc phosphide tablet trying to attempt suicide. He complained of only nausea upon presentation. At the ED, he was hemodynamically stable. Arterial blood gases showed a PH of 7.34, and bicarbonate of 19. He was immediately started on activated charcoal after gastric lavage. He was admitted directly to the medical ICU. A TTE was emergently done in the MICU and showed an EF of 54%. In the MICU, his ABGs showed a PH of 7.23 and bicarbonate of 13. He was started on Nexium drip to suppress gastric acidity, and sodium bicarbonate. His blood pressure started to drop in a few hours, so he was started on noradrenaline infusion. Another TTE was done after 6 hours and showed an EF of 20%. He was started on dobutamine infusion. The patient had cardiac arrest the next day from refractory cardiogenic shock despite the resuscitative measures.

Discussion

Zinc phosphide toxicity is a rare entity that presents more among farmers in developing countries because of the easy access. The phosphine gas released after the ingestion inhibits cytochrome c oxidase, disrupting the mitochondrial physiology and oxidative phosphorylation. This mechanism is responsible for the lethal side effects of zinc phosphide toxicity. Toxicity usually occurs within minutes of exposure, and symptoms include gastrointestinal irritation marked by nausea, vomiting, hematemesis, cardiogenic shock with refractory hypotension caused by direct cardiac toxicity, arrhythmias, hemorrhagic pulmonary edema with tachypnea, cough, acute respiratory distress syndrome, and respiratory failure. The mortality rate is very high within the first day of therapy. Management usually is supportive treatment. No antidote has been proved effective against zinc phosphide toxicity.

36 Cardiac tamponade secondary to covid-19

W Kogler*

MB Omar

F Kandah

J Ruiz

University of Florida College of Medicine- Jacksonville, Jacksonville, FL

Case Report

As the COVID-19 pandemic unfolds across the globe the spectrum of clinical presentations has grown.It has become clear that this virus significantly effects the cardiovascular system causing myocarditis, pericarditis, and pericardial effusion. So far, cardiac tamponade has been scarcely reported in COVID-19 patients.

A 51 year old obese, hypertensive, African American female presented with pleuritic chest pain and worsening dyspnea on exertion. She had been on day 5 of COVID-19 illness. At presentation, heart rate was 115 bpm, blood pressure was 95/50 mmHg and cool extremities were noted. EKG was significant for low voltage complexes and diffuse ST elevations. Initial Troponin T was 0.93 ng/ml. CT chest revealed scattered, patchy, bilateral ground glass opacities. TTE revealed a small effusion with inflammatory exudate, late diastolic collapse of the right atrium, compression of the right ventricle, excessive respiratory variation of the mitral and tricuspid valves, and an EF of 20%. Intravenous fluids were initiated and pericardial window was planned for the following day. However, at 12 hours of admission to the ICU, the patient developed a ventricular fibrillation cardiac arrest. Emergent bedside pericardiocentesis was prefromed, there was subsequent refractory PEA arrest and the patient expired at 13 hours of presentation.

COVID-19 has only been reported in a handful of case reports as being a cause of cardiac tamponade. COVID-19 has been reported to trigger an exaggerated systemic inflammatory response in patients and has been implicated in many cases of myocarditis/pericarditis which makes the proposed mechanism of this disease process very plausible.

37 Treatment of chylothorax following coronary artery bypass grafting with thoracic duct embolization

MH El-Farra1*

N Pham2

J Smith3

M Kajitani2

N Hasaniya1,2

1University of California Riverside, Riverside, CA

2Saint Bernardine Medical Center, Saint Bernardine Medical Center, San Bernardino, CA, US, hospital, San Bernardino, CA

3Loma Linda University Adventist Health Sciences Center, Loma Linda, CA

Introduction

Chylothorax is a rare complication after coronary artery bypass grafting (CABG). We present a case of chylothorax post-CABG that was treated with embolization of the thoracic duct.

Case Presentation

A 60-year-old male underwent a successful CABGx4 using the left internal mammary artery to the left anterior descending artery. Postoperatively, the chest tube’s output was 500–600 mL/day. On post-operative day 4, the chest tube’s drainage turned into orange milky fluid that was confirmed to be chyle. Initially, he was treated conservatively with fasting, total parenteral nutrition, and octreotide intravenously for 10 days. Initially there was improvement of both chest tube output and consistency of the drainage. However, the drainage returned back to high output chylous drainage after beginning oral feeding.

After failure of conservative medical treatment, thoracic duct embolization was planned. Lymphangiogram was preformed, and no leakage could be found even after challenging him with a fatty meal. There was retrograde reflux of contrast from the upper thoracic duct into upper mediastinal/periaortic lymphatics. The thoracic duct was embolized with platinum coils and nBCA glue.

The patient was kept NPO on total parenteral nutrition for three days post coiling then oral feeding was started and advance from liquid to regular diet. The chest tube output continued to be clear and the output was minimum. The drains were removed on post-operative day 3, and the patient was discharged home. On two weeks follow up, the patient returned with no complications and continues to be stable.

Conclusion

The current treatment options for chylothorax include: conservative medical treatment, thoracic duct embolization and surgical ligation of the thoracic duct. Thoracic duct embolization is a minimally invasive approach that should be considered by clinicians when chest tube output is high and medical treatment fails.

38 A case of covid-19 associated multisystem inflammatory syndrome resulting in new onset heart failure in an adult

M Bulathsinghala1*

R Samson2

1LSU Health Sciences Center, New Orleans, LA

2Tulane Health Sciences Center, New Orleans, LA

Case Report

COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare complication seen 2 to 6 weeks after the resolution of an acute COVID-19 infection. There is only one previously described case of COVID-19 related hyperinflammatory syndrome in adults. Here we present a case of COVID-19 associated MIS causing myocarditis and new onset heart failure with reduced ejection fraction in an adult.

Case

A 23 year-old man presented with fever, fatigue, exercise intolerance, myalgias, headaches, and a positive COVID-19 PCR test approximately 5 weeks earlier. On admission, the patient was noted to be febrile to 102.2°F, tachycardic, and hypotensive. Physical exam was notable for bilateral conjunctival irritation and trace lower extremity edema. Labs on admit were significant for creatine of 1.67 mg/dl, mild transaminitis, BNP 262 pg/ml, Troponin 0.67 ng/ml, and WBC 12.8 103/ul. Bedside echo performed in the Emergency Department was significant for a decreased LVEF 40–45%, global hypokinesis, and collapsible IVC. The patient was empirically treated with vancomycin and zosyn for possible sepsis however blood cultures remained clear and no source of infection was ever identified. Inflammatory markers were elevated with a LDH 252 U/L, D-Dimer 588 ng/ml, Ferritin 1,500 ng/ml, CPK 108 U/L, and CRP of 28 mg/dl. Angiogram of his chest showed no evidence of acute cardiopulmonary/airspace disease and no pulmonary embolism. Troponins peaked at 1.64 ng/ml and CRP peaked at 37 mg/dl.

Discussion

The patient continued to worsen with no obvious source of infection with a pattern of inflammatory markers consistent with MIS in the setting of recent COVID-19 infection. The severity of his presentation prompted treating the patient according to MIS-C guidelines developed for children which included IVIG, IV steroids, and high dose aspirin which resulted in a quick resolution of his fever and improvement in his cardiac function and end-organ labs and markers. The patient was discharged home on aspirin and pantoprazole. Follow up echocardiogram one month later demonstrated a return of normal cardiac function.

Allergy, immunology, inflammation and rheumatology

2:45 PM

Thursday, February 25, 2021

39 Subunit vaccination elicited lung trm cells to facilitate serotype independent immunity against k. pneumoniae

N Iwanaga*

J Kolls

Tulane University, New Orleans, LA

Purpose of Study

The emergence of multidrug-resistant strains of Klebsiella pneumoniae (Kp) has become a global threat. Because cellular and humoral immunity are key components of protection against this pulmonary pathogen, we decided to develop a vaccine strategy that engages both types of immunological responses.

Methods Used

Mice were first intratracheally vaccinated with Outer membrane protein X (OmpX) of Kp serotype 2, adjuvanted with heat-labile enterotoxin A1 domain (LTA1), and boosted 3 weeks after the initial immunization. Vaccinated C57Bl/6, B cell-deficient (mMT), and IL-17ra DermoCre mice – IL17ra is deleted in lung fibroblasts, were challenged with K1 strain. Lung T-cell responses were evaluated by FACS and ELISPOT. K1 strain-specific antibodies were measured by ELISA. RNA signature of CD4 T cells from vaccinated lungs was defined by single-cell RNA sequencing, and cellular features were examined by hematoxylin-eosin stain, immunofluorescence, and RNA scope.

Summary of Results

Vaccination elicited robust local T cell immunity (Th1 and Th17), which conferred significant protection against pulmonary challenge with the heterologous K1 strain (log CFU, mock: 8.339 ± 7.837, vaccinated: 2.96 ± 1.682, p = 0.0001), and prevented the dissemination from the lung to the spleen (mock: 5.662 ± 5.333, vaccinated: 1.312 ± 1.002, p < 0.0001). Despite pulmonary protection in vaccinated µMT mice, bacteria still disseminated to the spleens (log CFU, lung: 3.716 ± 3 .254, spleen: 5.311 ± 5.119). The efficacy was completely abrogated in the IL17ra DermoCre+ mice (lung: 7.929 ± 7.332, spleen: 5.487 ± 5.321). Vaccination triggered the formation of inducible bronchus-associated lymphoid tissue, however, it appeared less severe in IL-17ra DermoCre+ mice.

Conclusions

IL-17R signaling in fibroblasts plays an important role in protective pulmonary immunity triggered by mucosal vaccination, while B cells and likely cross-reactive antibodies are key to prevent bacterial dissemination. These data support mucosal vaccination’s therapeutic relevance with K. pneumoniae, which stimulates the simultaneous engagement of cellular and humoral immunity after pulmonary challenge with hypervirulent K. pneumoniae.

40 The suppression of collagen induced arthritis using collagen with post-translational modifications

HH Odens*

V Woo-Rasberry

A Kang

L Myers

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Purpose of Study

Rheumatoid Arthritis is an autoimmune arthritis involving degradation of cartilage, hyperplasia of the synovium, and infiltration of mononuclear cells. Collagen has been proposed as a potential suppressive agent for autoimmune arthritis because it can stimulate the Leukocyte-associated immunoglobulin-like receptor 1 (LAIR-1) which suppresses the activity of immune cells such as CD4+ Th1 cells. Post-translational modifications (PTM) are essential processes used by eukaryotic cells to diversify their protein functions and dynamically coordinate their signaling networks. Recently there has been a renaissance of interest in the possibility that citrullination (Cit) of proteins triggers more severe inflammation. The goal of this research was to use the collagen-induced arthritis animal model to test whether citrullination of Type I(I) collagen chains would alter its ability to suppress collagen induced arthritis (CIA).

Methods Used

Groups of 10 DR1 mice were injected intraperitoneally with either: (1) Type I(I) collagen chains, (2) citrullinated Type I(I) collagen chains, or (3) phosphate-buffered saline (PBS). Each mouse was given four doses of 100µg each over the span of four weeks and the severity of arthritis were determined by visual examination. Each mouse was scored thrice weekly and the mean severity score was recorded at each time point.

Summary of Results

We found that Type 1(I) significantly reduced the severity of arthritis in the DR1 mice while mice treated with cit- Type 1(I) developed more severe arthritis (severity scores of 0.5±1 vs 4.9 ± 6, p ≤ 0.04). The antibody responses to collagen were also studied to compare the outcomes following each treatment. Results demonstrated that mice treated with the non-cit Type I(I) collagen group had lower antibody levels to native type II collagen compared to the citrullinated Type I(I) collagen group and the PBS control group. These mice also had significantly lower antibody titers to cit type I collagen.

Conclusions

This data suggests that type I collagen suppresses both the severity of arthritis and the antibody titers to collagen probably by stimulating LAIR-1 and that citrullination of the collagen interferes with this process.

41 Novel humanized mouse model for donor selection in organ transplantation

A Ajith1*

D Horuzsko2

R Kapoor3,2

L Mulloy3,2

A Horuzsko1,2

1Georgia Cancer Center, Augusta, GA

2Augusta University, Augusta, GA

3Philadelphia College of Osteopathic Medicine South Georgia, Moultrie, GA and

Purpose of Study

Solid organ transplantation has been a life-saving procedure for thousands of patients worldwide. Recent advances on improving donor-screening diagnostics have aimed at identification of the most immunocompatible donor for the transplant recipient to maximize allograft survival. Current standards of donor selection relies on HLA typing and in vitro mixed lymphocyte reaction (MLR) which do not take into account the in vivo environment and adaptable nature of recipient’s immune system. Humanized mouse models are an appealing alternative that permits personalized investigation of the immunocompatibility of potential donor tissues for the recipient human immune system without putting patients at risk. By utilizing genomics, molecular and cellular anlysis of allogeniec response we asses the effeciency of our novel humanized mouse model to asses the donor-recepient compatibility and demonstrate it to be significantly more sensitive than conventional screening methods.

Methods Used

HLA typing and MLR for histocompatibility.

NSG mice subjected to irradiation (2Gy) and i.v lnjection of 8×106PBMCs from tranplsant recepient.

For allogeneic immune response, humanized mouse received 3 × 105PBMCs from unrelated donors(UD) or related donors(RD).

Whole genome transcirptome analysis and RT-PCR Transplant rejection array.

Summary of Results

The allogeneic UD challenge induced significant spleenomegaly with infiltration of activated cytotoxic hCD8+CD25+T cells expressing Perforin, GranzymeB annd IFNγ.Amongst the RDs, RD1 showed minimal allogeniec response while RD2 promoted higher cytotoxic CD8+T cells infiltration, indicating that RD1 has superior immunocompatibility with the recepient than RD2. Conversely MLR and HLA typing had failed to diferrentiate the 2 RDs showing them to have equal immunocompatibility with the recepient.

Conclusions

NSG-PBMC humanized mouse model was able to identify the RD exhibiting least allogeneic response to the recepient. This model is significantly more immunologically sensitive than conventional MLR and HLA typing for selection of an immunocompatible donor for the transplant recepient.

42 T follicular helper cells are involved in obesity-associated autoimmunity in lupus-prone mice

R Patel1*

J Meng2

X Shi2

T Washington1

H Ali1

T Posas-Mendoza1

R Quinet1

W Davis1

J Zakem1

Z You2

X Zhang1

1Ochsner Health System, New Orleans, LA

2Tulane University Health Science Center, New Orleans, LA

Purpose of Study

System lupus erythematosus (SLE) is a progressive autoimmune disease characterized with autoantibodies and multiple organs lesion. Epidemiological studies suggest a positive correlation between lupus severity and obesity. It remains unknown whether high fat diet (HFD) indeed exacerbate the pathology associated with SLE and underlying mechanism. Here we investigated the role of T follicular helper (Tfh) cells in the pathological link of HFD-induced obesity and SLE using MRL/lpr lupus prone mice.

Methods Used

Thirty MRL/lpr mice were randomized fed with a regular diet (RD) or HFD (60% fat-derived calories). Their body weights were recorded weekly. SLE progression was monitored by skin lesion, urine protein, titer of anti-dsDNA and anti-nuclear antibody (ANA). At week 14, spleen, kidney, and dorsum of neck skin were embedded for H&E, PAS, Masson’s staining for histopathological lupus lesions and quantified as skin score and kidney index. Germinal centers (GCs) and Tfh cells in spleen were identified by immunohistochemistry staining and flow cytometry.

Summary of Results

Obesity was achieved with significant difference of mouse body weight between the RD and HFD groups from week 3 to week 14 (p<0.05 to p<0.01). Evidence of SLE development, such as skin rash in HFD group showed up as earlier as week 6 with higher probability (55.6% in HFD group vs 11.1% in RD group) (p<0.05). Proteinuria was increased from 11 to 14 week in HFD group. Increase trend of anti-dsDNA titer was detected in HFD group but no difference of ANA in these two groups. HFD mice had a higher histological score of skin (p<0.05) and higher kidney index than RD mice. The size of GCs and frequency of Tfh cells in the spleen were increased in HFD group.

Conclusions

Our results show HFD-induced obesity exacerbates lupus development in MRL/lpr mice. Tfh cells may be involved in this process of SLE autoimmunity development. Interventions to reduce body weight or target Tfh cells may improve both lupus symptoms and outcomes in genetically predisposed SLE patients.

43 Lupus nephritis, other clinical features and their association with antiphospholipid antibody positivity in patients with lupus

PP Jain*

D Kamen

J Oates

Medical University of South Carolina, Charleston, SC

Purpose of Study

Antiphospholipid antibody positivity (aPL) is associated with elevated thrombosis among patients with systemic lupus erythematosus (SLE). The goal of our study was to determine whether aPL seropositivity correlates with lupus nephritis (LN) and other clinical features among patients with SLE.

Methods Used

We used data from a longitudinal registry of SLE patients seen at our institution from 2003–2020. Patients with SLE were selected using a case-control design based on having known aPL and/or lupus anticoagulant (LAC). aPL included IgM and IgG anticardiolipin and anti-b2glycoprotein. Demographic information, American College of Rheumatology (ACR) classification criteria, and renal biopsies were evaluated. Statistical analysis was performed using Pearson’s chi-squared testing for categorical measures.

Summary of Results

399 patients with SLE were evaluated. 49.3% had history of LN. Majority of patients were African American (AA) (72.1%). AA patients with SLE were more likely to develop LN compared to non-AA (59.3%, 26.4%, p<0.01), consistent with known health disparities previously described. Patients with childhood-onset SLE were significantly more likely to develop LN compared to those diagnosed in adulthood (67.1, 45.8, p<0.01). LN patients were more likely to be aPL positive compared to those without nephritis (56.9%, 45.10%, p=0.02). Furthermore, patients were significantly (p<0.05) more likely to have neurological disorder (seizures/psychosis) with any aPL or LAC positivity, discoid rash with any positive aPL, and thrombocytopenia with positive LAC (table 1).

Abstract 43 Table 1

Conclusions

Within a predominately AA population of patients with SLE, elevated levels of aPL are associated with LN, in addition to discoid rashes and seizures/psychosis. LAC, but not aPL positivity alone, was associated with thrombocytopenia. AA and childhood-onset SLE patients were more likely to develop LN. Future studies will explore a molecular basis for these associations and the impact on aPL treatment strategies.

44 Anti-pseudomonas antibodies and lung disease in cystic fibrosis

S Lu*

J Kolls

Tulane University, New Orleans, LA

Purpose of Study

Cystic fibrosis (CF) is an inherited lethal disease caused by mutations in CFTR (cystic fibrosis transmembrane conductance regulator). Approximately, 60% of patients with are homozygous for the F508del mutation. Although nearly 100% of these patients have pancreatic insufficiency but in contrast lung function is quite variable suggesting modifier genes may play a role in lung disease. To this end a gene modifier study showed that class II MHC alleles are associated with the age of first detectable Pseudomonas aeruginosa (PA) infection and lung function. Thus, we thought to assess if serological responses to PA varied among CF subjects with normal lung function versus reduce lung function.

Methods Used

We screened anti-mucoid PA antibodies in patients’ sera by ELISA and confirmed their PA-specific surface binding by FACS. Immunoprecipitation-proteomics were performed using outer membrane protein and human serum to identify the potential antigen. Mice were immunized by either purified OprI, extracted outer membrane proteins or whole PA three times subcutaneously and challenged with 107 of alive PA one week after last immunization intratracheally. All mice were sacrificed at 24hr or 72hr post-challenge, daily weight loss was monitored, serum had been collected to examine anti-PA antibodies while lung tissue used for histology and immunohistochemistry.

Summary of Results

High titers of anti-mucoid PA antibodies as well as antibodies directly against OprI were found in chronically PA infected patients, even higher in patients with worse lung function than the ones with better lung function. Therefore, we hypothesized that anti-PA antibody may contribute to tissue damage by immunocomplex deposition in the lung, instead of preventing infection. Results showed immunized mice displayed more severe inflammation and more weight loss than unimmunized controls, along with a higher titer of anti-OprI or anti-PA antibodies. Furthermore, no weight loss was observed in immunized Rag2KO mice, which lack B cells and T cells, suggesting a role of adaptive immunity in the pathology.

Conclusions

These data suggest that one mechanism by which class II MHC is a modifier gene in CF is through antigen presentation and determining the types of anti-PA antibodies are generated in CF.

Infectious diseases

2:45 PM

Thursday, February 25, 2021

45 Variation in hospitalist-specific antibiotic prescribing at 4 hospitals: a novel tool for antibiotic stewardship

Z Wiley1,2*

J Kubes2

KA Jones2

J Jacob1,2

M Sexton1,2

S Suchindran1,2

R Dantes1,2

S Fridkin1

1Emory University School of Medicine, Atlanta, GA

2Emory Healthcare, Atlanta, GA

Purpose of Study

Describe antibiotic (abx) prescribing variation among hospitalists within a healthcare system.

Methods Used

A novel hospitalist-specific abx prescribing metric was developed by linking billing data to abx administration records in 4 hospitals (2 academic (AMC1, AMC2) and 2 community (CH1, CH2) from 1/2016- 12/2018. Dates hospitalist billed for a patient = billed patient-days (bPD);each abx day of therapy (DOT) mapped to a bPD. Each DOT classified to 4 abx categories:broad-spectrum hospital-onset (BS-HO), broad-spectrum community-onset (BS-CO), anti-MRSA, and highest risk for C. difficile infection (CDI). DOT and bPD pooled to calculate hospitalist-specific DOT/1000 bPD. Best subsets regression performed to assess model fit and generate hospital and abx category-specific models adjusting for patient-level factors (e.g. comorbidities). Models used to calculate predicted hospitalist-specific DOT and observed:expected (O:E) ratios for each abx category. Kruskal-Wallis tests and pairwise Wilcoxon ranked-sum tests used to determine differences between median DOT/1000 bPD and O:E between hospitals for each abx category.

Summary of Results

116 hospitalists from 4 hospitals contributed 437,303 bPD. Median DOT/1000 bPD varied between hospitals (BS-HO: 46.7–84.2; BS-CO: 63.3–100; anti-MRSA: 48.4–65.4; CDI: 82.0–129.4). CH2 had significantly higher median DOT/1000 bPD compared to AMC 1/AMC 2 (all abx categories p < 0.001) and CH1 (BS-HO: p=0.01; Anti-MRSA: p=0.02). 4 abx groups at 4 hospitals produced 16 models:model fit good for CH2 (R2 > 0.55 for all models), modest for AMC2 (R20.46–0.55), fair for CH1 (R20.19–0.35), and poor for AMC1 (R2 < 0.12 for all models). Variation in hospitalist-specific O:E was moderate (IQR 0.9–1.1) though AMC1 showed greater variation with no significant differences in median O:E between hospitals (all abx categories p > 0.1).

Conclusions

Adjusting for patient-level factors reduced much of the variation in hospitalist-specific DOT/1000 bPD in some but not all hospitals, suggesting that factors besides comorbidities may drive prescribing. This hospitalist-specific abx prescribing metric may represent a target for stewardship intervention (e.g. hospitalist-specific feedback of prescribing).

46 Management and outcomes of nucleic acid amplification test positive/toxin negative clostridioides difficile patients in a single center

AP Sun1*

I Chirca2

1Dwight David Eisenhower Army Medical Center, Augusta, GA

2University Hospital, Augusta, GA

Purpose of Study

To follow the treatment regimens and clinical outcomes of NAAT positive toxin EIA negative patients.

Methods Used

In a single center from October 2018 to June 2019, we instituted a nursing protocol for C. diff testing. If the patient had ≥3 soft, loose, or liquid stools in 24 hours within the first 3 days of admission, nursing was to place them on contact precautions submit a non-formed stool sample. Stricter criteria for stool sample submission were implemented from hospital day 4 onward. Samples initially underwent NAAT with positive NAAT results prompting further testing with a toxin A and B EIA. NAAT positive/toxin negative patients were then followed further and data on their management and outcomes were obtained. Management data included the initiation of isolation, initiation of treatment, antibiotic used, and duration of treatment. Clinical outcome data included recurrence of C. diff infection, 30-day readmissions, and readmissions directly related to C. diff.

Summary of Results

A total of 163 NAAT positive toxin EIA negative patients were identified. 153 patients (96.3%) received isolation orders and 122 patients (74.8%) received treatment. Regimens varied widely with either oral Vancomycin, Metronidazole, or Fidaxomicin as did duration of treatment (1–26 days). Of the patients treated, 20 (12.2% of total, 16.3% of treated) developed recurrent C. diff, 23 (14.1% of total, 18.9% of treated) were re-admitted within 30 days, and 8 (4.9% of total, 6.6% of treated) were due to C. diff infection. Of those untreated, 8 (4.9% of total, 19.5% of untreated) had recurrent C. diff, 10 (6.1% of total, 24.4% of untreated) were re-admitted, and 2 (1.2% of total, 4.9% of untreated) were due to C. diff infection.

Conclusions

The majority of NAAT positive/toxin negative patients received treatment with greatly varying regimens and durations. Despite treatment of this population, there was no significant difference in rates of recurrence, 30-day readmission, and readmissions due to C. diff. Our data suggests overtreatment of NAAT positive/toxin negative patients.

47 Covid-19 in kidney transplant recipients: experience from a large health system in louisiana

A Torres-Ortiz1*

J Walker2

J Velez1

J Garces1

1Ochsner Medical Center – New Orleans, New Orleans, LA

2The University of Queensland Faculty of Medicine, Herston, Australia

Purpose of Study

The purpose of this study is to share the experience in our center and generate medical evidence on the effect of immunsuppression in the outcomes of kidney transplant recipients with Coronavirus Disease-19 (COVID-19).

Methods Used

We conducted a retrospective study in kidney transplant recipients from a single health system that were diagnosed with COVID-19 based on a positive real-time reverse transcription polymerase chain reaction test for SARS-CoV-2 RNA between 03/01/2020 and 04/30/2020. We compared them with affected patients without a kidney transplant and without any kind of immunosuppressive medication (control). We examined the rates of hospitalization, intensive-care unit (ICU) admission, acute kidney injury (AKI) and mortality as outcome measures.

Summary of Results

A total of 8473 patients were diagnosed with COVID-19 within our Health System within the study period. Thirty-three (0.4%) were kidney transplant recipients. Sixteen of the 33 (48%) were admitted to the hospital (median age of 56, 68% males, 93% African American) vs 2201 admissions (25%) for the control group (median age 66, 48% males, 65% African-American), i.e., a significantly greater risk for hospitalization for transplant recipients (p = 0.002). Percentage of patients with hypertension in the transplant group was numerically higher (93% vs 80%, p = 0.06), as well as the number of ICU admissions (43% vs 28%, p = 0.055). AKI was more common in transplant patients (81% vs 33.8% p<0.0001). No difference in mortality was observed (31 vs 24%, p = 0.34). Among transplant patients, those hospitalized were more likely to be on prednisone (75% vs 35%, p = 0.025) and had a post-transplant graft life of 7.9 years compared to 5.5 years for those not hospitalized (p=0.08).

Conclusions

Kidney transplant recipients affected with COVID-19 exhibited a greater incidence of hospitalization, AKI and a trend for more ICU admissions. Use of immunosuppression with prednisone was associated with greater risk for hospitalization.

48 Nontuberculous mycobacterial infections in end-stage renal disease patients: prevalence, risk factors, and mortality

E Toth1*

S Tran2

J Waller1

W Bollag1

AA Mohammed1

B Siddiqui1

M Kheda1

SL Baer2

1Augusta University, Augusta, GA

2Augusta VA Medical Center, Augusta, GA

Purpose of Study

Nontuberculous mycobacterial disease (NTM) has increased in the United States. However, there is little known on NTM in the end-stage renal disease (ESRD) population. We investigated ESRD patients to determine risk factors for NTM disease and mortality.

Methods Used

We queried the United States Renal Data System using ICD-9/ICD-10 codes from 2005–2015 to identify NTM and risk factors. Logistic regression was used to examine the association of risk factors with NTM and Cox proportional hazards modeling was used to assess the association of NTM with mortality.

Summary of Results

3,232 (0.3%) individuals were identified as having any NTM infection. The prevalence was 0.1% for non-cutaneous and 0.02% for cutaneous NTM. Demographic characteristics that were protective for NTM included female sex [odds ratio (OR)=0.87, 95% confidence interval (CI)=0.81–0.93] and using hemodialysis versus peritoneal dialysis (OR=0.10, CI=0.08–0.13). Being black (OR=1.27, CI=1.18–1.37) or other race (OR=1.39, CI=1.21–1.59) increased the risk of NTM. Clinical variables associated with increased risk for NTM diagnosis included HIV (OR=15.71, CI=14.24–17.33), chronic lung disease (OR=2.32, CI=2.17–2.49), history of any transplant (OR=4.25, CI=3.93–4.60), kidney transplant (OR=3.00, CI=2.75–3.27), diabetes (OR=1.32, CI=1.23–1.43), cancer (OR=1.77, CI=1.63–1.93), rheumatologic disease (OR=1.92, CI=1.77–2.08), liver disease (OR=2.09, CI=1.91–2.30), and cardiovascular disease (OR=2.75, CI=2.49–3.04). Pulmonary (HR=1.33, CI=1.24–1.43), cutaneous (HR=1.24, CI=1.04–1.48), disseminated (HR=1.34, CI=1.23–1.45), other specified (HR=1.20, CI=1.08–1.34), and unspecified (HR=1.44, CI=1.33–1.546) NTM were associated with increased mortality in multivariable analysis.

Conclusions

Controlling for relevant demographic and clinical risk factors, there was an increased risk of mortality associated with any diagnosis of NTM. Early diagnosis and treatment of NTM infection in ESRD patients may improve survival in this population.

49 Cord blood for the assessment of early onset sepsis in preterm newborns

SM Lerma Narvaez*

University of Texas Medical Branch, Cypress, TX

Purpose of Study

In Preterm infants, Early-Onset sepsis is a major cause of morbidity and mortality. Routinely, blood is drawn for blood culture, CBC, and blood group cross-match which may be >10 mL/kg. In an era of quality improvement, the emphasis is placed on better utilization of medical care resources like umbilical cord blood. In preterm infants, umbilical cord blood can be used for lab tests at admission thereby avoiding significant blood loss in the first hour (the golden hour). The objective of the study is to investigate if Umbilical Cord Blood can be safely used to measure the biomarkers of Early Onset Sepsis in Preterm infants.

Methods Used

After Institutional Review Board approval, under sterile conditions, we collected umbilical blood samples for blood culture, complete blood counts, and biomarkers of sepsis (Presepsin, Procalcitonin, and C-Reactive Protein) from Preterm Infants. We used ELISA to measure biomarkers of sepsis.

Summary of Results

We included 64 Preterm infants with mean gestation 32.15 +2.2 weeks, birth weight 1853 + 519 grams. There were 37 (58%) male infants, 69% mothers received prenatal steroids for lung maturity, 39% mother received antenatal antibiotics, 5% mothers had chorioamnionitis, 16% had premature prolonged rupture of membranes, 82% delivered by cesarean section. Cord blood presepsin levels 4.65 + 1.7 ng/mL (normal range 0.4 – 3.98 ng/mL and cut off for sepsis >92 ng/mL), C-Reactive Protein 0.04 + 0.01 mg/dL (Normal range <1 mg/dL and cut off for sepsis >1 mg/dL), Procalcitonin 188.3 + 371µg/mL (normal range 0.005 – 0.02µg/mL). Total white cell count was 8256 +2965 and Inmature to Total neutrophile ratio (IT ratio) 0.09 + 0.13. None of the cord blood and neonatal blood cultures showed bacterial growth.

Abstract 49 Table 1

Levels of different biomarkers of sepsis in Cord blood

Conclusions

Our study demonstrated that cord blood can be used to assess EOS except procalcitonin were very high.

50 Is the reported association of parenteral diarreha and pediatric urniary tract infections a medical myth?

C Murray*

L Mellick

S Kalra

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Purpose of Study

The association of non-infectious diarrhea with extra-intestinal infections such as otitis media, pneumonia or febrile urinary tract infections is commonly known as parenteral diarrhea. The primary research question was to determine if there is an association between urinary tract infections and reports of diarrhea.

Methods Used

A retrospective chart review was performed from 2017–2019 at our children’s hospital. We searched for afebrile and febrile urinary tract infections in children under 5 years of age in the pediatric emergency department or admitted directly. Exclusion criteria included children with recent urological procedures, known urinary tract disease, immune suppression, sepsis or known gastrointestinal diseases. The medical records were reviewed for reports of concurrent diarrhea. A retrospective review of two specific noninfectious chief complaints, closed head injuries and extremity fractures,to compare the background rate of associated diarrhea.

Summary of Results

A total 392 cases were reviewed. Culture positive urine collections were obtained in 60.2% of children and culture negative urines were noted in 39.8% of patients. Diarrhea was reported in 18.6% of the cases of culture positive urinary tract infections and 16.7% of culture negative. This was not statistically different. Of the children with negative urine cultures 65.4% had a documented febrile illness suggesting another infectious etiology. In the control group of 211 patients who visited the pediatric ED for closed head injuries, associated diarrhea was reported in 0.9%. This difference was strongly statistically significant. In the control group of 157 patients presenting with extremity fractures there were no reports of diarrhea. We further analyzed febrile versus afebrile urinary tract infections. The incidence of diarrhea between febrile culture proven urinary tract infections and all children with culture proven urinary tract infections was similar and not statistically different.

Conclusions

There appears to be an association between urinary tract infections and extra-intestinal or parenteral diarrhea. Diarrhea occurred in 18.6% of a large case series of children with culture proven urinary tract infections and in 0.9% and 0% of patients presenting to the ED for closed head injuries and extremity fractures.

Endocrinology and metabolism

9:00 AM

Friday, February 26, 2021

51 Muscle mitochondrial function analysis in adults with type 1 diabetes

D Gottlieb1,2*

J Reusch1

K Nadeau1

K Tommerdahl1

L Abushamat1

JE Regensteiner1

M Cee-Green1

I Schauer1

1University of Colorado Denver, Denver, CO

2Tulane University SOM, New Orleans, LA

Purpose of Study

People with type 1 diabetes (T1D) develop excess cardiovascular disease (CVD), a predictor of premature mortality. CVD in T1D relates to impaired insulin sensitivity, vascular function and possibly mitochondrial function. We sought to compare in vivo and ex vivo measures of mitochondrial function in adults with and without T1D to better understand contributions of vascular substrate delivery versus mitochondrial structural defects.

Methods Used

Adults with and without T1D matched for age and sex were enrolled. Post-exercise mitochondrial function was assessed in vivo using 31phosphorous magnetic resonance spectroscopy. Ex vivo function in muscle biopsy samples was measured via mitochondrial oxygen consumption with lipid and carbohydrate substrates in permeabilized muscle fibers using Oroboros Oxygraph O2K Respirometry. Hyperinsulinemic euglycemic clamps were performed to determine insulin sensitivity. Groups were compared with Student’s t-tests.

Summary of Results

Seventy-two participants were enrolled (with T1D: n=51, age 40±14 years, BMI 27.1±3.2 kg/m2 and without T1D: n=21, age 45±11 years, BMI 30.5±5.5 kg/m2) (table 1). Insulin sensitivity was lower (p≤0.0001) in T1D, as were in vivo maximum mitochondrial capacity (Qmax) and mitochondrial efficiency (ME). In vivo rates of anaerobic glycolysis were higher in T1D. Ex vivo analysis demonstrated decreased coupled oxygen consumption with both carbohydrate and lipid substrates in T1D.

Abstract 51 Table 1

Conclusions

The data suggest that during exercise, adults with T1D preferentially utilize anaerobic glycolysis while having reduced mitochondrial capacity. Ex vivo differences suggest intrinsic impairment of mitochondrial oxygen utilization during carbohydrate and lipid metabolism independent of vascular oxygen or substrate supply. Understanding why these changes occur may lead to the development of new therapies to prevent CVD in T1D.

52 Estrogen supplementation is associated with higher quality of life scores in women with cystic fibrosis

M Wu1,2*

N Arora3

V Sueblinvong1

WR Hunt1

V Tangpricha1

1Emory University School of Medicine, Atlanta, GA

2Children’s Healthcare of Atlanta, Atlanta, GA

3Emory University Emory College of Arts and Sciences, Atlanta, GA

Purpose of Study

With rapid advancements in therapeutic options for patients with cystic fibrosis (CF), the median predicted survival has increased to 47 years along with the prevalence of non-pulmonary complications for patients with CF. Women with CF suffer irregular menses, sexual dysfunction and low bone mineral density. With increasing pregnancies among women with CF, they may consider contraception. Estrogen supplementation may modulate these outcomes and others. The purpose of this study was to explore the effects of supplemental estrogen use on quality of life (QOL) in CF.

Methods Used

Women with CF ages 16–50 years were administered a validated CF-specific QOL survey (CFQ-R) during a clinic visit through an IRB-approved cross-sectional study. The QOL domain scores of subjects taking and not taking estrogen were compared pairwise by Kruskal Wallis tests and overall by Wilcoxon signed rank test.

Summary of Results

The estrogen exposed and estrogen unexposed subjects with CF had similar age, BMI, FEV1, race, CF mutation, pancreatic sufficiency and diabetes status. The estrogen exposed subjects were taking 20–30 mcg of ethinyl estradiol in oral contraceptive pills. The median and IQR for the QOL scores are shown in figure 1. The estrogen exposed subjects had consistently higher QOL scores than the estrogen unexposed subjects (p=0.001). The estrogen exposed subjects had significantly higher scores in 7 of the 12 CFQ-R categories: physical, vitality, treatment burden and role domains and weight, respiratory and digestion symptom scales (p<0.05).

Conclusions

Estrogen supplementation was associated with improved quality of life in women with CF. This cross-sectional study highlights the need for further investigation into the potential benefits of estrogen supplementation. The dose, route, formulation and timing of estrogen therapy may impact the beneficial effects for women with CF.

53 Sodium-glucose cotransporter 2 inhibition attenuates the intrarenal renin-angiotensin system in a rat model of polycystic ovary syndrome

J Pruett1*

S Everman1

ED Torres Fernandez2

D Romero1,3

L Yanes Cardozo1,3

1University of Mississippi Medical Center, Jackson, MS

2The University of Texas at Austin, Dell Medical School, Austin, TX

3Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age. PCOS is characterized by hyperandrogenemia and ovulatory dysfunction, and it is highly co-prevalent with several cardiovascular risk factors such as obesity, increased blood pressure (BP), and insulin resistance (IR). The renin-angiotensin system (RAS) appears to be dysregulated in PCOS as well. Current treatments for these cardiovascular risk factors in PCOS are lackluster. We tested the hypothesis that administration of a sodium-glucose cotransporter 2 inhibitor (SGLT2i) will attenuate the RAS in a PCOS rat model.

Methods Used

Four-week old Sprague Dawley female rats were randomized to either control or dihydrotestosterone (7.5 mg/90 days). At 12 weeks old (wo), rats were divided to receive drinking water or the SGLT2i empagliflozin (10 mg/kg/day) for 3 weeks (n=7–10 per group). Adiposity was analyzed by EchoMRI. Renal cortices and medullas were collected for real time PCR for intrarenal RAS components. Angiotensin-converting enzyme (ACE) activity was measured fluorometrically. BP was measured by radiotelemetry during SGLT2i treatment.

Summary of Results

PCOS rats have increased adiposity, leptin, IR, renal ACE mRNA expression, and BP. SGLT2i decreased fat mass (21.1 ± 2.7 vs 12.2 ± 0.8 g, P<0.01) and leptin (0.86 ± 0.16 vs 0.45 ± 0.05 ng/mL, P<0.05) in PCOS. SGLT2i decreased BP in PCOS. In the renal medulla of PCOS, SGLT2i decreased mRNA expression of ACE and angiotensin II type 1 receptor. Furthermore, in PCOS, SGLT2i decreased medullary ACE activity (5573.0 ± 563.4 vs 3707.1 ± 430.2 nmol/min/mg, P<0.01). However, plasma ACE and IR were unchanged by SGLT2i in PCOS.

Conclusions

SGLT2i decreases activation of the intrarenal RAS in PCOS, which was associated with decreased adiposity, leptin, and BP. This suggests that SGLT2i, through attenuation of the intrarenal RAS, could be a novel therapeutic agent for reducing BP and obesity in women with PCOS. Funded by COBRE/MS CEPR P20GM121334.

54 Alterations in the molecular pathways involved in the expression of hyaluronan in human pancreatic islets

EA Cruz1*

N Lenchik2

I Gerling2

1The University of Tennessee Health Science Center College of Medicine, Memphis, TN

2The University of Tennessee Health Science Center, The University of Tennessee Health Science Center, Memphis, TN, US, Memphis, TN

Purpose of Study

Type 1 Diabetes (T1D) affects many individuals and is an autoimmune disorder that involves the destruction of β pancreatic islet cells. In islets that experience inflammatory responses, hyaluronan, hyaluronic acid (HA), has been found to accumulate in the extracellular matrix (ECM). However, the relationship between HA and T1D is not fully understood. Low molecular weight HA (LMW-HA) has been associated with the inflammatory pathways involved in the progression of T1D.

Methods Used

To better determine the role HA plays in the progression of islet inflammation (insulitis), we analyze prior data from 260 pancreatic islet samples. The samples are obtained from the Network for Pancreatic Organ Donors (NPOD). Samples are grouped by disease state: Control, AB+(prediabetes), T1D. The samples are then stained to produce four groups of islets: Ins+CD3-(normal), Ins+CD3+(insulitis), Ins-CD3+, and Ins-CD3-. Pancreatic islets are isolated through laser capture microdissection. RNA transcriptomes are collected and analyzed by unpaired, uneven t-tests. Literature review and data mining with WebGestalt into geneontology and KEGG pathways are performed to identify genes of interest.

Summary of Results

Genes involved in pathways involving HA are found to be differentially expressed in islets with insulitis and those without. The genes found are associated with CD44 cascade signaling, leukocyte recruitment, apoptosis, ECM degradation, angiogenesis, and β cell function and differentiation. HYAL2 is increased in islets that are AB+ which suggests that LMW-HA may be abundant in islets prior to insulitis, and the LMW-HA binding with receptors such as CD44 may cause cascade events which promotes leukocyte recruitment and infiltration.

Conclusions

Better understanding of the relationship between HA and T1D inflammatory pathways may provide biomarkers to provide better predictive indicators in the progression and management of T1D, and our data provides the opportunity to further explore the mechanisms involved in T1D and HA.

55 Microrna-21 overexpression ameliorates cardiometabolic outcomes in a mouse model of polycystic ovary syndrome

M Cummins*

A Huffman

S Rezq

J Basnet

M Syed

J Reckelhoff

L Yanes Cardozo

D Romero

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

Polycystic Ovarian Syndrome (PCOS), the most common endocrine disorder in reproductive age women, is characterized by androgen excess, ovulatory dysfunction, and polycystic ovaries. PCOS is associated with a number of cardiometabolic dysregulations. MicroRNA-21 expression is dynamically regulated in tissues involved in PCOS pathophysiology. Adipose expansion via hyperplastic as opposed to hypertrophic growth has been associated with improved cardiometabolic outcomes. We aim to determine the role of microRNA-21 overexpression on cardiometabolic outcomes in a mouse model of PCOS by comparison of frequency distributions of adipocyte size in three key fat depots.

Methods Used

Three-week old microRNA-21 overexpression (miR21OE) or wild-type (WT) C57BL/6J female mice were implanted s.c. with silastic tubes containing the androgen dihydrotestosterone (DHT) or placebo for 90 days. Body weights were taken weekly. Body composition was determined by Echo-MRI. Adipocyte size was determined in H&E stained adipose tissue (mesenteric, retroperitoneal, and subcutaneous fat depots) sections using ImageJ software with the Adiposoft plugin. Two-way ANOVA and Kolmogorov-Smirnov statistical analyses were performed using GraphPad Prism.

Summary of Results

DHT significantly increased body weight in both WT and miR21OE mice compared to their controls. There was a significant increase in the fat/lean mass ratio in DHT-treated WT mice but not in DHT-treated miR21OE mice. DHT decreased the frequency of small adipocytes and increased the frequency of large adipocytes in all three fat depots analyzed. MiR21OE mice showed an attenuation in the decrease of small adipocyte and in the increase of large adipocyte frequencies in all three fat depots in DHT-treated mice.

Conclusions

MiR21OE mice had an ameliorated response to deleterious cardiometabolic outcomes associated with elevated androgens. The pronounced change in hyperplastic adipose expansion in fat depots of DHT-treated miR21OE animals indicates the potential mechanism by which these animals may have increased protection. MicroRNA-21 supplementation could be a novel therapeutic approach for PCOS cardiometabolic dysregulations.

56 A novel diabetes screening: audio classification using deep learning (pilot study)

P Suppakitjanusant1*

ZH Aung3

B Ongphiphadhanakul1

V Tangpricha2

1Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand

2Emory University School of Medicine, Atlanta, GA

3Mahidol University Faculty of Engineering, Nakorn Pathom, Thailand

Purpose of Study

Artificial intelligence will play an important role in the future in the medical field, especially in medical diagnosis. The potential of employing deep learning for audio-based detection by voice recordings in early diagnosis of Alzheimer’s disease, Parkinson’s disease, and depression are being explored. Inspired by these promising results, we aim to develop a non-invasive audio-based diabetes voice screening system that utilizes deep learning. We hypothesized that high blood glucose levels would cause laryngeal soft tissue swelling, leading to changes in certain voice characteristics.

Methods Used

A prospective case-control study was performed in subjects recruited from the Endocrinology Clinic at Emory Healthcare from January to March 2020. We extracted voice spectrograms via the mel-frequency cepstral coefficient from 5-second samples of a sustained/a/vowel. Moreover, we designed a convolutional neural network (CNN) architecture together with the K-Nearest Neighbour algorithm to classify voice samples into two classes representing the presence or absence of diabetes.

Summary of Results

There were a total of 24 subjects consisting of 17 people with diabetes and 7 people without diabetes in this study. The races of participants were African American 58.33%, Caucasian 33.33%, and others 8.33% The mean age of the participants with diabetes was significantly older than healthy participants (55.00 ± 8.86 years vs 28.60 ± 7.00 years, p-value <0.001). Participants with diabetes had an average duration of diabetes for 9.00 ± 8.97 years. Overall, performances of diabetes classification are 83.34% sensitivity, 50% specificity, and 67 ± 17% accuracy with a low random chance (Cohen’s kappa coefficient 0.33).

Conclusions

The proposed CNN algorithm has high performance to differentiate voice samples from people with and without diabetes. Based on this pilot study, a deep learning-based voice analysis holds promise in identifying patients who may have undiagnosed diabetes.

Hematology and oncology

9:00AM

Friday, February 26, 2021

57 Effects of extracellular microrna on the tumorigenesis of colorectal cancer using orthotopic xenograft mouse model

J Simon1*

L McKean Baste1

S Baker1

A Klinger1

G Maresh1

L Hellmers1

A Bhattarai1

X Zhang1

C Salomon2

D Margolin1

J Paruch1

L Li1

1Ochsner Health System, New Orleans, LA

2The University of Queensland Faculty of Humanities and Social Sciences, Saint Lucia, Australia

Purpose of Study

MicroRNAs (miRNAs) are short non-coding RNAs implicated in post-transcriptional regulation of gene expression. Abnormal expression of miRNAs in cancer is associated with enhanced tumorigenesis/metastases. Our previous data showed that lymph node stromal cells (LNSC) secreted extracellular vesicles (EV) may enhance tumorigenesis via miRNAs. Here we show the effect of EV miRNAs in colorectal cancer (CRC) progression using gain- and loss-of-function approaches in orthotopic mouse models.

Methods Used

Total miRNA sequencing was analyzed using in silico computer prediction model (DIANA-miRPATH v2.0). Four overexpressed miRNAs in LNSC EV were selected (miR-155-5p, miR-199a-3p, mi-143-3p, and mi-214-3p). Tumor cell proliferation assay was done using CRC SW620 cell line transfected with selected miRNA mimics or inhibitors. In vivo, luciferase tagged SW620 cells transfected with selected miRNA mimics, inhibitors, or controls were injected into the rectal submucosa of NOD/SCID mice. Tumor growth and metastases were observed by weekly bioluminescent imaging (BLI). At week 7, tumors were weighed and the BLIs of the tumors and organs were recorded. Immunohistochemistry staining was done to confirm.

Summary of Results

The mimics of all four miRNAs significantly increased SW620 cell proliferation (p<0.01 to p<0.001). The inhibitor of miR-199a-3p suppressed SW620 cell proliferation (p<0.05). In our orthotopic mouse model, compared with controls, groups with SW620 cells transfected with mimics of miR-199a-3p and miR-143-3p had higher frequencies of tumorigenesis (94% and 66.6% vs. 14%), liver/lung metastases, and tumor BLI. Mice with miRNA-199a-3p inhibitor transfected SW620 cells showed a trend of lower BLI and tumor growth than controls.

Conclusions

Our gain- and loss-of-function studies show that miRNAs carried in LNSC-EV are crucial for CRC tumor progression. Elaborating their role will provide new insight into the interplay between LNSCs and CRC cells. These miRNAs may serve as potential therapeutic targets for CRC patients.

58 Nanoparticle-based stimulation of human CD8+ t cells and their use in a patient-derived orthotopic mouse model

C Haupt*

X Zhang

G Maresh

L Baste

N Mathew

A Bhattarai

D Margolin

L Li

Ochsner, New Orleans, LA

Purpose of Study

Humanized mice are a staple for cancer research. Traditionally, normal donor PBMC are isolated and engrafted in immunocompromised mice. In order to model the patient, it is necessary to use patient PBMC. However, patient cells are limited. Here, we present a method for isolating and expanding normal PBMC for mouse humanization, specifically CD8+ T cells, which are capable of robust anti-tumor activity. We aim to refine this method on patient PBMC for use in a patient-derived orthotopic mouse model.

Methods Used

CD8+ T cells were isolated from PBMC and stimulated in RPMI with rhIL-2 and aAPC coated with aCD3 and aCD28. On day 7, cells were engrafted to Rag2-/- IL2Rγ-/- mice. Another group was injected with cells starved of IL-2 for 2 days post-stimulation. At day 28 post-injection, blood, spleens, and peritoneal washes were collected. Cells were analyzed with FACS.

Summary of Results

In vitro stimulation yielded up to 70-fold expansion of CD8+ cells by day 7. CD8+ cells were found in the peritoneal space at day 28. Cells exhibited a central and effector memory phenotype. PD-1 expression on cells introduced into mice after in vitro stimulation remained low.

Abstract 58 Figure 1

In vitro stimulation yielded up to 70-fold expansion of CD8+ cells by day 7. CD8+ cells are in the peritoneal space at day 28

Abstract 58 Figure 2

FACS analysis of cells collected from the peritoneal space of engrafted mice.

Conclusions

Our aAPC mediate robust expansion of normal human donor CD8+ cells. The cells were only found in the peritoneal washes which is insufficient for successful grafting. Growth optimization and further characterization is needed to successfully emulate the cancer patient in our mice.

59 The gene expression profile of triple-negative breast cancer after neoadjuvant chemotherapy

A Philipovskiy1*

S Gaur1

K Chambers2

R Gamez2

R McCallum1

R Kirken3

R Aguilera3

S Roy3

1Texas Tech University Health Science Center, El Paso, TX

2Texas Tech University Health Sciences Center El Paso, El Paso, TX

3University of Texas El Paso, El Paso, TX

Purpose of Study

Triple-negative breast cancer (TNBC) is a heterogeneous subtype of breast cancer characterized by the absence of any targetable receptors. Over decades chemotherapy remains the only medical option. Historically, neoadjuvant chemotherapy (NACT) has been used to downstage unresectable breast cancer to allow better locoregional control. Currently, the best predictive marker for the disease recurrence is pathological complete response (pCR) after the NACT. However, the response rate to chemotherapy is only 40%, and there is no marker to predict resistance of tumors to chemotherapy.

To better understand which patients will achieve pCR, we analyzed the gene expression profile of 15 patients with TNBC before and after NACT.

Methods Used

We analyzed formalin-fixed tumor samples from fifteen women diagnosed with stage (I-III) TNBC between 2014–2019. We have compared the gene expression profile of patients before and after NACT. We have compared gene expression profiles between patients who achieved pCR with patients with RD. Genomic DNA was extracted, enriched, and sequenced from all exomes on the Illumina HiSeq. Genomic data were then processed through a bioinformatics platform to identify genomic alterations and gene expression profiles.

Summary of Results

Genomic analysis of TNBC samples identified 12682 genes commonly expressed after NACT in a group of patients with RD. In the same group, 446 genes were upregulated significantly after NACT, and 275 were significantly downregulated. Among commonly upregulated genes related to cancer, we identified GLI1, DUSP1, EGR1/3, ATF2, c-JUN. The commonly upregulated pathways after NACT were pathways encoding extracellular matrix–remodeling, DNA-damage response pathway, and pathways related to resistance to chemotherapy.

Conclusions

Our data suggest that gene expression profiling can be used to identify patients with chemoresistant type of TNBC. This can potentially help medical oncologists to avoid excessive toxicity from NACT and consider surgical options first.

60 High false negative rate and high mortality: COVID-19 infection in patients with hematological malignancies

A Niu*

B Ning

T Hu

NS Saba

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Patients with hematological malignancies (HM) are immunocompromised and considered high-risk for COVID-19. Their immune response to COVID-19 may differ from that of immunocompetent hosts. The aim of this study was to evaluate COVID-19 detection in patients with HM and their overall clinical course.

Methods Used

This observational study examined patients with a variety of HM with high suspicion for COVID-19. All were tested with guideline-directed nasopharyngeal RT-PCR. For a subset of patients who tested negative, clustered regularly interspaced short palindromic repeats (CRISPR) technology was used for COVID-19 detection. The false negative rate and overall mortality of all patients was examined.

Summary of Results

We examined 29 patients (age 24–82) from 3/31/20 to 7/17/20 with a variety of HM for COVID-19. 16 patients tested positive for COVID-19 with nasopharyngeal RT-PCR testing, while 13 patients tested negative. We then used CRISPR technology to test 8 patients who initially tested negative by RT-PCR. Surprisingly, 7 of the 8 patients tested positive for COVID-19 with either a blood sample and/or nasal swab for the SARS-CoV-2 specific N gene and ORF1ab gene. Excluding patients who were negative by RT-PCR and not tested by CRISPR, the rate of false negativity with RT-PCR testing was 29%. A fatality of 31% was noted. Of the 23 positive patients, 8 patients received COVID-19-directed therapy while 4 patients expired. Of the 8 treated patients, 7 improved while 1 patient expired.

Conclusions

29 patients with a variety of HM (20 lymphoid, 9 myeloid) were examined for COVID-19. 10 patients had undergone stem cell transplantation (SCT), 15 were on chemotherapy (notably lymphodepleting chemotherapy), and 4 were on surveillance. As COVID-19 is associated with worsening lymphopenia, our patients’ symptoms and immune response to COVID-19 likely differed from immunocompetent hosts. This translated into an overall worse outcome as seen by the high mortality rate. Therefore, it is imperative to establish COVID-19 diagnosis quickly, as faster initiation of treatment has been associated with better outcomes. However, due to a strikingly high false negative rate, high clinical suspicion must guide further workup and therapy in patients with HM who present with an undiagnosed respiratory illness consistent with COVID-19.

61 Glyceraldehyde-3-phosphate dehydrogenase prevents deleterious effects of anti-tumor drug etoposide on vascular smooth muscle cells

I Nikolli*

P Delafontaine

S Sukhanov

Tulane University, New Orleans, LA

Purpose of Study

Etoposide (ET) is a chemotherapy drug, pro-oxidant, and genotoxic agent possessing several off-target effects. We have shown previously that overexpression of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) protects vascular smooth muscle cells (SMC) against oxidative stress-induced DNA damage and apoptosis via upregulation of Ape1 endonuclease. We hypothesize that GAPDH overexpression will prevent the deleterious effects of ET on SMC.

Methods Used

Expression of GAPDH, Ape1, pH2AX(S139) (DNA damage marker), cleaved caspase-3 (apoptotic marker) was quantified by immunoblotting, cell apoptosis - by Cell Death ELISA. Caspase 3/7 activity and ET-induced cytotoxic effect were quantified in live cells using the Incucyte SX5 system with IncuCyte Caspase 3/7 Red and IncuCyte Cytotox Red reagents, respectively. GAPDH was overexpressed by using pLenti-GAPDH virus (100 MOI, 24 hrs) and pLenti-GFP virus was used as control.

Summary of Results

SMC were exposed to eight ET doses (2–240 uM) for 16h. ET decreased GAPDH and Ape1 levels (20uM ET: 54±6% and 41±7% decreased respectively compared to control, p<0.05), elicited a potent DNA damage (pH2AX increase by 1.7-fold, p<0.05) and induced cell apoptosis (cleaved Caspase-3 increase by 2.3-fold, p<0.05). The effects of cytotoxicity were only observed in ET treatment of (>20uM) in a dose-depended manner. Plenti-GAPDH virus increased GAPDH levels 2-fold, and Ape1 levels by 64±7% compared to control (p<0.05). GAPDH overexpression induced a rightward shift in the cytotoxicity dose-response curve (control, EC50, 76±2uM; pLenti-GAPDH, EC50, 121±3uM) suggesting a protective effect. ET dose-dependently activated caspase 3/7 in control virus-infected SMC (EC50, 41±2uM) and GAPDH overexpression shifted ET/caspase dose-response curve to the right (EC50, 47±2uM) indicating a decrease in caspase activation. GAPDH overexpression suppressed ET-induced SMC apoptosis (ELISA: 60uM ET, control, A(409–490), 0.44±0.03, pLenti-GAPDH, A(409–490), 0.33±0.03, p<0.05).

Conclusions

GAPDH overexpression decreased ET-induced cytotoxicity, downregulated caspase 3/7 activation, and suppressed SMC apoptosis. Our results suggest that SMC-targeted GAPDH upregulation is a novel potential approach to diminish deleterious effects of ET’ chemotherapy on vascular cells.

62 Identification and characterization of desmoplastic small round cell tumor cancer stem cells

JW Magrath*

A Hartono

S Lee

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Desmoplastic Small Round Cell Tumor (DSRCT) is a rare form of pediatric cancer that normally arises in the abdominal or pelvic cavity. Despite treatment with a combination of surgery, radiotherapy, and chemotherapy, the prognosis remains poor with a 5-year survival rate of 15–25%. One potential explanation for DSRCT’s poor treatment response is the existence of a subpopulation of cells known as cancer stem cells (CSCs). CSCs are chemoresistant, and can initiate tumors and form metastases. CSCs have been identified in a variety of tumors, including the closely related Ewing Sarcoma, which like DSRCT contains a translocation involving the EWSR1 gene. However, a CSC population has yet to be identified in DSRCT. Identifying and characterizing DSRCT CSCs will be an important step toward understanding and treating this deadly malignancy.

Methods Used

Novel culture conditions excluding serum were established that allow DSRCT cells to grow as spheres. Cells were harvested and the expression of stemness genes was assessed using RT-qPCR and Western Blot. Flow cytometry will be used to investigate potential CSC markers including CD133 and CD44. To definitively establish the existence of a CSC population, the ability of DSRCT cells to form tumors at low seeding densities in NOD-SCID mice will be examined.

Summary of Results

DSRCT cells grown under novel culture conditions form spheres and morphologically resemble CSCs. The stemness markers Nanog, OCT4, and SOX2 were found to be upregulated at the transcriptional level in BER-DSRCT and JN-DSRCT cell lines. Current work has demonstrated upregulation of Nanog protein and will examine the protein expression of OCT4 and SOX2. Preliminary in vivo tumor seeding experiments have demonstrated the ability of 104 DSRCT cells grown under sphere-forming culture conditions to form tumors in NOD-SCID, while 107 adherently-grown cells are needed to initiate tumor formation.

Conclusions

DSRCT is a deadly cancer without effective therapeutic options. The existence of a CSC population could explain its treatment resistance making it critical to identify and characterize this population to facilitate future therapy development. This work provides preliminary evidence of the existence of a DSRCT CSC population. Future work will confirm this existence and test potential therapeutic targets.

Gastroenterology, nutrition & dietary supplements

10:45 AM

Friday, February 26, 2021

63 Interactions between body composition and predictors of cirrhosis in patients with non-alcoholic fatty liver disease

J Sitta*

E Florez

B Obert

J Reese

J Stork

E Varney

CM Howard

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of cirrhosis and it closely relates to obesity, diabetes, and dyslipidemia. Increased tissue fat deposition is associated with NAFLD’s pathogenesis; however, its association with cirrhosis progression has not been well studied. This study assessed the relationship of fat distribution and muscle composition with NAFLD index in a diverse population diagnosed with NAFLD.

Methods Used

For this HIPPA-compliant, IRB-approved, retrospective study, adult patients with various degrees of NAFLD and non-enhanced CT images of the abdomen and pelvis were selected (N=681). Patients whose CT did not meet the minimum necessary parameters were excluded (N=116), totaling a final sample of 565 subjects. A sub-group of 286 patients with available clinical data to calculate the NAFLD index was analyzed from the final cohort. The segmentation of fat and muscle depots was performed on 24 CT slices centered at the L4-L5 intervertebral space, using a validated segmentation software. Pearson and Spearman correlation coefficients were used to associate measurements of body composition with the NAFLD index.

Summary of Results

Total muscle volume to total fat volume ratio showed an inverse correlation with BMI (rs = -0.53, p<0.0001) and NAFLD index (rs = -0.31, p<0.0001), which was higher in diabetics (rs= -0.60 and -0.43 respectively, p<0.0001). Total muscle attenuation showed an inverse correlation with visceral fat volume (rs= -0.31, p<0.0001) and with NAFLD index (R= -0.40, p<0.0001), which was higher in diabetics (rs= -0.49, p<0.0001). A multiple regression analysis model for predicting NAFLD index was performed: NAFLD = 1.6616+0.0786*BMI +0.0520*age+0.0145*total muscle attenuation+0.0221*total fat attenuation (R2 =0.43, p<0.001).

Conclusions

In patients diagnosed with NAFLD, skeletal muscle to fat volume ratio and muscle attenuation, which are measures of sarcopenic obesity and myosteatosis respectively, were linked to increased risk of cirrhosis, particularly in individuals with diabetes. These findings highlight the importance of body composition assessment to guide clinical management in patients with NAFLD.

64 The recognition of a new pattern of gastric emptying in symptomatic patients

GM Galura*

J Diaz

R McCallum

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Purpose of Study

Gastric emptying scintigraphy (GES) is the gold standard test utilized for the diagnosis of gastric motility disorders. Gastroparesis is characterized by delayed gastric emptying (GE). Dumping syndrome is distinguished by its early-onset rapid GE, both having varying degrees of post-prandial symptoms. We have observed a pattern of delayed-onset rapid gastric emptying (DRGE) in symptomatic subjects whose GE was interpreted as normal (<10% remaining at 4 hrs). Our objective was to identify the frequency of this entity in a large cohort of Hispanic-dominated, symptomatic patients who underwent a solid meal GES.

Methods Used

The hourly GE decrements of 24 normal, asymptomatic, female-dominated subjects had been previously studied. The mean decrements and their respective standard deviations (SD) were obtained, and the upper limit cut-off values were set at +1 SD. We reviewed the GES results from symptomatic patients, performed in our institution from November 1, 2019, to October 1, 2020. Only GES, which were read as normal using traditional criteria (<10% remaining at 4 hrs), were included in the study.

Summary of Results

We analyzed 122 GES results. The upper limit threshold of normal GE decrements (mean +1 SD) were 52.1% for 12 hr, 37.2% for 2–3 hr, and 19.0% for 3–4 hours. After applying the new cut-offs to the 122 GES results, we identified 10 patients (8.2%), 9 females, whose GE decrements exceeded these established thresholds. 3 patients (2.5%) exceeded the 1–2 hr decrement, 5 (4.1%) exceeded decrements for the 2–3 hr cap, and 2 patients (1.6%) had GE decrements that exceeded the 3–4 hr limit. All subjects had post-prandial symptoms with varying degrees of nausea, vomiting, fullness, abdominal pain, and stool urgency, which coincided with the hourly abnormal decrements. Outpatient follow-up management confirmed that pre-prandial anticholinergic therapy (dicyclomine) resolved those symptoms.

Conclusions

We report a new entity DRGE, observed in 8.2% of patients whose GES was normal by current criteria. This new GE pattern explains their symptoms, which subsequently responded to appropriate medical therapy. Additional data is required to establish this syndrome’s incidence in larger sample sizes and other ethnic groups.

65 Impact of surfactant protein-a on immunomodulatory properties of human and murine breast milk

CM Meyer*

JL Alcorn

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, Houston, TX

Purpose of Study

Human breast milk is known to reduce the incidence of necrotizing enterocolitis (NEC) in infants. Our previous mouse studies demonstrated that exogenous surfactant protein-A (SP-A) modulates intestinal inflammation and reduces the rates of NEC-like illnesses in SP-A-deficient pups. Published work suggests may breast milk contain SP-A. We hypothesize that SP-A is present in human and mouse breast milk and impacts inflammatory cytokines expression in mouse ileum.

Methods Used

Human breast milk was collected at postpartum days 3 and 28. Mouse milk at postpartum days 1 to 10. The presence of SP-A in collected breast milk was detected through immunoprecipitation and Western blot analysis. The impact of wildtype (WT) mouse milk on SP-A-deficient (SPAKO) pup ileum was evaluated by a series of cross-rearing experiments. Pups were sacrificed on day of life (DOL) 7, 14, and 21 and expression of cytokine mRNA in terminal ileum was determined by real-time qRT-PCR.

Summary of Results

SP-A was detected in human breast milk and wildtype mouse breast milk, but not in SPAKO breast milk. Expression of TLR-4, IL-1β, IL-6, and TNF-α was decreased in SPAKO pups housed with WT dams compared to SPAKO pups housed with SPAKO dams at all ages, but was significant only on DOL 14. In WT pups housed with SPAKO dams (compared to WT pups housed with WT dams) there was no difference in cytokine levels at all ages. However, TLR-4 levels were higher on DOL 14 and 21 in cross reared WT pups compared to controls, but only significant on DOL14.

Conclusions

SP-A is secreted in human and murine breast milk and plays a role in lowering baseline inflammation in murine pup terminal ileum at baseline. The peak effect of inflammatory depression associated with SP-A ingestion via breast milk was at DOL 14 in mouse pups, which correlates with human intestinal maturity of 26–32 weeks gestation, a critical period in the development of NEC in humans. This temporal relationship suggests that SP-A ingestion via breast milk may contribute to breast milk’s protective effect against NEC. Currently, we are assessing the effect of models of intestinal injury on inflammation and intestinal damage using the cross-rearing model.

66 Evaluation of dysphagia in children: a single center experience

AE Quantrille1*

T Benes1

R Patel1,2

J Winer1,2

E McCoy1,2

K Ferguson-Paul1,2

1The University of Tennessee Health Science Center College of Medicine, Memphis, TN

2Le Bonheur Children’s Hospital, Memphis, TN

Purpose of Study

At our institution we saw an increase in gastrostomy tube (g-tube) placements for patients with dysphagia in 2018. In 2019 we standardized our management with a multidisciplinary team. The purpose of our study is to compare the method of diagnosis, interventions and management of dysphagia at our institution in 2018 vs 2019.

Methods Used

We retrospectively reviewed the charts of 192 patients with dysphagia admitted to Le Bonheur Children’s Hospital August 2018-December 2019. Demographics, presenting symptoms, co-morbid conditions, modified barium swallow (MBS) results and interventions such as thickener and g-tube placement were recorded.

Summary of Results

A total of 105 charts were reviewed from 2018 and 87 from 2019. The majority of patients with dysphagia were premature infants 25–28 weeks gestation (53.3% vs 70.1%). The top 3 presenting symptoms were respiratory distress with feeds (51%), choking with feeds (34%) and difficulty with feeds/growth (29.2%). Laryngeal cleft was the most common ENT comorbidity in 2018 vs 2019 (40.4% vs 10.9%, p=0.001). Prolaryn® injection was done more often in 2018 (44.2% vs. 6.5%, p= 0.001) and 2019 saw a rise in bedside scopes (60.9% vs 30.8%, p=0.003). More patients had an abnormal MBS done in 2018 vs 2019 (90.2% vs 83.7%, p=0.185) but more were diagnosed with dysphagia prior to having an MBS in 2019 (19.5% vs 18.1%, p=0.854). In 2018 more patients had improvement on repeat MBS following interventions (83.3% vs. 44.6%, p=0.001). The most common recommendations in 2018 vs 2019 were no oral feeding (30.4% vs 15.1%) and honey thickened feeds (34.3% vs. 30.2%). G-tube placement decreased from 51.4% in 2018 to 31% in 2019 (p=0.004).

Conclusions

Infants and children with difficulty feeding and respiratory distress with feeds should be evaluated for dysphagia. Characteristic symptoms may correlate with an abnormal MBS. Trialing honey thickened feeds and acid blockers in patients with dysphagia without frank aspiration is a reasonable approach. A multidisciplinary team may help to elucidate the diagnosis. Optimal timing of repeat MBS after interventions is an area of further study. G-tube placement may be safely prevented by conservative medical management without increased risk of aspiration.

67 Improving the rate of nonselective beta-blocker therapy in veterans diagnosed with esophageal varices

EM Petryna1*

B Waters1,2

1University of Tennessee Health Science Center, Memphis, TN

2Memphis VA Medical Center, Memphis, TN

Purpose of Study

Esophageal variceal hemorrhage results in significant increase in morbidity and mortality. The Department of Veterans Affairs created an Advanced Liver Disease dashboard to identify cirrhosis patients and to track their care. This quality improvement project was designed to ensure that cirrhosis patients with the diagnosis of esophageal varices are treated with nonselective beta-blocker therapy, and identify gaps in care.

Methods Used

At the Memphis VAMC, the Advanced Liver Disease Dashboard was queried from June-October, 2020, 89 patients had the diagnosis of cirrhosis and esophageal varices without a current prescription of nonselective beta-blockers. Using the Computerized Patient Record System (CPRS), patients were analyzed for: documented esophagogastroduodenoscopy (EGD) screening, date of last screening, presence of varices on the last EGD, current treatment with propranolol, nadolol or carvedilol, and documented contraindications to beta-blocker therapy.

Summary of Results

89 patients had the diagnosis of cirrhosis and esophageal varices without a current non-selective beta-blocker prescription. 42/89 (47%) patients had resolution of varices. 9/89 did not have confirmed cirrhosis and varices, 1/89 had cirrhosis without varices but refused subsequent every three year EGD screening for varices. Of the 37 patients with varices, 7/37 patients were taking propranolol, nadolol or carvedilol; 11/37 had a lapse in their nonselective beta-blocker prescription, 8/37 (21.6%) had documented contraindications to beta-blockers. 8/37 were taking metoprolol. 3/37 were unable to be contacted. Patients identified with lapses in prescriptions had renewals. Patients on metoprolol were targeted for conversion to nonselective beta-blockers.

Conclusions

By identifying cirrhosis patients with a diagnosis of varices without recent beta-blocker prescription, it was found that 47% of patients had resolution of esophageal varices. Improved antiviral therapy may help explain such improvement in portal hypertension. Of those patients with varices, 21.6% had documented contraindications to beta-blockers. Utilizing this database, a significant number of patients with lapses in nonselective beta blocker prescriptions and use of metoprolol were identified.

68 Primary fetal non-human primate organoid models for intestinal development and inflammation

KY Burge1*

J Eckert1

J Papin2

DN Reuter

D Myers

H Chaaban1

1University of Oklahoma Health Sciences Center, Oklahoma City, OK

2The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Purpose of Study

Necrotizing enterocolitis (NEC), the most common gastrointestinal emergency in preterm infants, is a difficult disease to model. Research in animal models has, thus far, failed to lead to major translational breakthroughs. Diverse and complex risk factors for the disease deem most models, though often incorporating multiple risk factors, physiologically simplistic. Organoids are 3D in vitro models, derived primarily from LGR5+ stem cells, that more closely recapitulate the epithelium of the in vivo organ. In the small intestine, stem cells from the crypts allow for continued proliferation of organoids in both size and number. While the cell-type composition of 3D organoid models is an improvement over traditional 2D monoculture, 2D monolayers composed of organoid-derived cells in physiologically-relevant composition enables access to both apical and basal sides of the epithelium.

Methods Used

We extracted fresh tissue from the terminal ileum of a male, c-sectioned, fetal olive baboon (Papio anubis), isolated intestinal crypts through a series of extractions and filtrations, and plated crypt fragments in 3D domes of basement membrane extract (BME). Once at sufficient density, organoids were passaged, trypsinized, and plated in Transwells coated with BME.

Summary of Results

Organoids in both 3D and 2D formats provide more physiologically meaningful data than experiments run in individual cell lines while retaining the relative simplicity of traditional cell culture methods. Additionally, derivation of organoids from a single source allows for longitudinal standardization of environmental and genetic factors. Organoids will be challenged with live bacteria and/or bacterial products to simulate intestinal inflammation during the neonatal period.

Conclusions

Non-human primate (NHP) in vitro models can advance neonatal NEC research as stepping stones between standard immortalized cell culture of individual cell lines and human intestinal organoid models, for which tissue is often difficult to acquire.

Health care research, quality improvement & patient safety, population health & precision medicine

10:45 AM

Friday, February 26, 2021

69 Do we know the dose of diuretics required for bronchopulmonary dysplasia in preterm infants?

S Osman*

S Munir

J Burdine

S Jain

The University of Texas Medical Branch at Galveston, Galveston, TX

Purpose of Study

Bronchopulmonary dysplasia (BPD) affects 50% of infants born with birth weight <1000 g. Diuretics are frequently used to manage BPD. Combination of hydrochlorothiazide and spironolactone is used at varying doses.The purpose of this study is to determine the correlation of the dose of diuretics used in the management of BPD and electrolyte abnormalities requiring supplementation.

Methods Used

In this observational retrospective study, we included all preterm infants (<30 weeks) born at the University of Texas Medical Branch in Galveston, Texas. Infants >36 weeks post menstrual age and received diuretics for BPD were included. Infants were divided into Group I which included infants who received half dose of hydrochlorothiazide and spironolactone (1 mg/kg) and in Group II infants received full dose hydrochlorothiazide and spironolactone (2 mg/kg/day). All infants received standard NICU care. Infants were monitored for hyponatremia,hypokalemia and hypochloremia and requiring sodium supplementation for hyponatremia. Hyponatremia was defined as serum sodium <133 mmol/L, hypokalemia <3.0 mmol/L and hypochloremia serum chloride <90 mmol/L.

Summary of Results

31 infants were included in the study (Group I =11 and group II =20). Between groups, there were no significant differences in gender, gestational age, birth weight, ethnicity, patent ductus arteriosus requiring treatment, intraventricular hemorrhage (grade >2), retinopathy of prematurity and necrotizing enterocolitis, maternal smoking and use of antenatal steroids. Chorioamnionitis (p = 0.03) and prolonged rupture of membranes (p = 0.05) occurred more frequently in group II. Severity of BPD between the groups was similar. Infants in group I had no hyponatremia, hypochloremia, and sodium supplementation for hyponatremia. Group II, 6 infants had hyponatremia (p = 0.06), 7had hypochloremia (p= 0.03) and 9 required sodium supplementation for hyponatremia and/or hypochloremia (p = 0.01).

Abstract 69 Table 1

Conclusions

Use of full dose diuretics cause electrolyte abnormalities requiring supplementation. Further studies are needed to determine if half diuretic dose is effective and safe.

70 A QI project to standardize management of gastroschisis in the nicu

L Dalal*

KM Kuehn

MG Johnson

C Domonoske

M Grant

M Austin

M Chang

C Aneji

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, Houston, TX

Purpose of Study

Gastroschisis is a congenital defect of the abdominal wall affecting 1 in every 10,000 deliveries. Patients with this defect are managed in the NICU with surgical and medical interventions However, there is a significant variation in the care provided within and between different NICUs. For other patient populations, evidence shows that standardizing care leads to better patient outcomes. The purpose of this quality improvement (QI) initiative is to standardize the care of gastroschisis patients from birth to discharge. This initial stage involved evaluating 12 years of patients who were managed for gastroschisis at our single-center to establish baseline data.

Methods Used

We conducted a retrospective chart review on all patients born with gastroschisis from December 2008 through May 2020 at Children’s Memorial Hermann in Houston, Texas. Patient outcomes of interest included the type of gastroschisis and surgical closure, antibiotics exposure, enteral and parenteral nutrition, and growth, and length of stay (LOS). Complex gastroschisis was defined as gastroschisis that presented along with intestinal atresia, perforation or volvulus.

Summary of Results

One hundred and fifty patients were included with 53.3% male, median gestational age of 36 weeks, and mean birthweight 2381 g. Most cases were simple (n=129, 86%) with only 21 complex cases. The median LOS was 37.5 and ranged from 13–291 days. LOS was affected by the complexity of gastroschisis, with simple having a significantly shorter LOS (P=0.0008). There was also a large amount of variability within each group, with average LOS for simple =50.9±46.9 days, and average LOS for complex = 120.5±80.4. TPN administration duration ranged between 8 and 257 days, with a median length of 26 days. Most (98%) received at least one course of antibiotics and 42% received two or more courses.

Conclusions

Management and outcomes for gastroschisis patients was variable, both across and within simple and complex cases. We have developed a guideline to standardize care of gastroschisis patients from birth through discharge. At six months and one year from the institution of the guideline, we will track the patients newly admitted and compare their outcomes to the baseline.

71 Well child care is affected by intrauterine substance exposure

C Suiter

M Woods*

DS Shah

East Tennessee State University James H Quillen College of Medicine, Johnson City, TN

Purpose of Study

To determine the difference between intrauterine substance exposure (ISE) and non intrauterine substance exposure (non-ISE) groups for well-child care (WCC) adherence, nonroutine healthcare use, vaccine completion and mortality in the first 2 years of life.

Methods Used

After local IRB approval, this cross-sectional study identified substance exposed infants seen at ETSU Pediatrics between January 1, 2014 - June 1, 2020 in the EHR using ICD-10 Codes. The patient information was extracted and de-identified by the Population Health Department at ETSU. This produced 724 substance exposed infants (ISE) and 1000 non-exposed (non-ISE) infants seen in the same time frame as a control group. The data was collected in Excel and analyzed by SPSS using an independent sample t-test to test for statistical significance. We defined total WCC adherence as completing all 8 successive well visits.

Summary of Results

There is a statistically significant difference in average well visits reported between the two groups as seen in table 1. However, a higher percentage of the non-ISE group completed all 8 WCC visits to earn total adherence. Similarly, there is a statistically significant difference in nonroutine visits and immunization rate. Mortality in the ISE group approaches significance.

Abstract 71 Table 1

Analysis of healthcare use between non-substance exposed and substance-exposed infants

Conclusions

WCC is affected by a history of ISE compared to non-exposure. WCC adherence, immunization rate and nonroutine healthcare use is significantly higher for the non-ISE group, while mortality is higher in the ISE group. Attention to WCC may improve mortality and health outcomes in at risk populations.

72 Lethal means assessment: resident initiative to improve screening for access to firearms in a pediatric emergency department

CL Stegall*

J Ayala

K Allen

K Barton

A Kumar-Veeraswamy

Medical University of South Carolina, Charleston, SC

Purpose of Study

Suicide is the second leading cause of death among adolescents in the United States. The most common method for completed suicide is use of a firearm. Studies have demonstrated emergency department (ED) providers do not adequately screen for access to firearms, including amongst pediatric psychiatric patients. Our study aims to increase the frequency of provider screening for access to firearms among pediatric patients presenting to the emergency department for a mental health complaint, as well as implement interventions for positive screens.

Methods Used

This is a resident-driven quality improvement project created for the pediatric emergency department setting. Baseline data of firearm screening rates was collected via a retrospective chart review of patients who presented to the Medical University of South Carolina’s Pediatric ED with the chief complaint of ‘psychiatric evaluation.’ Interventions included resident education, Be SMART training, a smart phrase to facilitate documentation, and workstation reminders. For positive screens, families were given Be SMART educational handouts and gun locks. Monthly chart reviews to determine frequency of screening and interventions made for positive screens were reviewed. Results were compared with the Wald technique to determine 95% confidence intervals.

Summary of Results

The baseline mean rate of monthly firearm screening prior to our first intervention was 14.38% (CI ± 4%), with 49 of 340 patients screened by ED providers. Of these 49 patients, 26 has positive screens. After our first intervention, firearm screening rates for month one increased to 25.8% (CI ± 10%) with 17 of 66 patients screened, and 8 positive screens. Month two increased to 32.4% (CI ± 11%) with 23 of 71 patients screened, and 14 positive screens.

Conclusions

Since many suicidal patients first present to an ED setting, ED providers should make the first intervention to establish a safe environment and mitigate risks for suicidal completion. Educational interventions focused on firearm screening for providers in a pediatric ED can have a positive impact on firearm screening rates for children presenting with mental health complaints. Future efforts will include seeking provider feedback to identify barriers to screening.

73 Impact of telehealth visit and socioeconomic status on hydroxyurea response in sickle cell anemia

S Shaner*

S Bhatia

J Lebensburger

The University of Alabama at Birmingham School of Medicine, Birmingham, AL

Purpose of Study

The UAB Pediatric Sickle Cell Clinic cares for patients at an academic center (UAB) and satellite clinics. Laboratory results are not available at point of care for satellite clinic patients but are available for the academic center patients. Therefore, hydroxyurea (HU) dosing changes are made via telehealth for the satellite clinic patients. We hypothesized that dose modifications via telehealth visits or patients socioeconomic status (SES) would not affect HU response.

Methods Used

One-year retrospective review of 172 patients prescribed HU at UAB (n=107) and satellite clinics (n=65). We abstracted age, clinic location, CBC, HbF, number of clinic or ED visits, and hospital admissions. SES was derived using residence zip code. We constructed two separate multivariable regression models to examine the impact of i) type of clinic visits; ii) SES status.

Summary of Results

The mean age of 172 participants was 11±5y, mean Hb was 8.5±1.1 g/dL, mean HbF% was 13±7. We identified 107 participants prescribed HU at the academic center and 65 at satellite clinics. The mean poverty level was 18±4, household income was 50,119±8,298, and 14.4% of adults had less than a high school diploma.

We identified no significant differences in age (11.5y vs 10.9, p=0.5), Hb (8.5 g/dL vs.8.6, p=0.6), HbF (13.2% vs.11.7, p=0.1), hospital admissions (0.99 vs. 0.85, p=0.5) or pain admissions per year (0.86 vs. 0.74, p=0.6) in Birmingham as compared to satellite clinic. Patients in Birmingham had a statistically higher number of clinic visits (2.9 vs 2.5, p=0.006). Satellite clinic patients were identified with significantly higher poverty level (p<0.01), lower median household income (p<0.01) and lower education (p<0.01). When analyzing HbF by socioeconomic data, we did not identify an association between HbF values with poverty level (p= 1.0), median household income (p=0.8) or percent of adults in the community with less than a high school diploma (p=0.7). In regression analysis, HbF% was associated with clinic visits (p=0.02) and age (p=0.003) but not associated with clinic location or socioeconomic data.

Conclusions

Our data demonstrate that telehealth for HU dosing provided a similar level of HU response to in-person HU dosing adjustments independent of clinic location or socioeconomic data.

74 Discrepant FIB-4 AND NFS scores in a primary care NAFLD cohort

A Schreiner*

S Livingston

J Marsden

J Zhang

M Gebregziabher

V Durkalski-Mauldin

D Koch

P Mauldin

D Rockey

W Moran

Medical University of South Carolina, Charleston, SC

Purpose of Study

Non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis risk are underdiagnosed and underassessed in primary care. Using natural language processing (NLP) to identify patients with radiographic evidence of hepatic steatosis, we evaluated the agreement between Fibrosis-4 (FIB-4) and NAFLD fibrosis scores (NFS) in primary care.

Methods Used

This retrospective cohort study of electronic record data included adults with at least one radiographic report of hepatic steatosis and no other known chronic liver disease. We calculated patient-level FIB-4 and NFS scores and categorized them by advanced fibrosis risk. The agreement between risk categories was analyzed using weighted kappa. Spearman correlation and Bland-Altman analysis were used to assess correlation and agreement in the continuous FIB-4 and NSF scales respectively. A multinomial logistic regression model was developed to evaluate the associations between clinical variables and discrepant FIB-4 and NFS results.

Summary of Results

The cohort included 767 patients with radiographic evidence of hepatic steatosis. Advanced fibrosis risk assessment categories disagreed in 43% of the sample and FIB-4 and NFS scores would have resulted in the different clinical decisions in 30% of patients. The weighted kappa statistic for FIB-4 and NFS category agreement was 0.41 (95% CI: 0.36 – 0.46) and the Spearman correlation coefficient for log FIB-4 and NFS was 0.64 (p < 0.001). The multinomial logistic regression analysis identified Black race (OR 2.64, 95% CI 1.84–3.78) and A1c (OR 1.37, 95% CI 1.23–1.52) with higher odds of having a higher NFS risk category than FIB-4.

Conclusions

In a primary care NAFLD cohort created by applying NLP to radiographic report results in an EHR, FIB-4 and NFS fibrosis risk scores were often in disagreement. Non-invasive test selection can impact clinical decision making and may contribute to racial disparities of care.

Cardiovascular I

1:00 PM

Friday, February 26, 2021

75 Predictors of major adverse cardiovascular outcomes in SARS-CoV-2 patients admitted to a quarternery healthcare system serving southwest us

M Sidhu*

Methodist Health System, Dallas, TX

Purpose of Study

As a predominantly respiratory viral illness, it comes as no surprise that severe respiratory failure has portended greater risk of mortality in SARS-CoV-2 patients. Data on the predictors of major adverse cardiovascular events (MACE) in SARS-CoV-2 infected patients is limited and at times providing conflicting reports.

Methods Used

A retrospective review was performed on 500 hospitalized patients that tested positive for SARS CoV-2 between March and July 2020 at a major quaternary health care system in a metropolitan area of the southwestern United States. Baseline characteristics, co-morbidities, medications, presenting complaints, vitals, telemetry, electrocardiograms, echocardiograms, laboratory values and clinical outcomes of their disease course were identified. Analyses were performed on this patient pool, which was divided into two cohorts: (i) patients that experienced a MACE [a composite of myocardial infarction (MI), stroke, pulmonary embolism (PE), deep venous thrombosis (DVT), or shock requiring vasopressor support] and (ii) patients that did not experience a MACE. Pearson’s chi square test was used to examine the difference in mortality between those who had a MACE and those who did not have a MACE.

Summary of Results

Of the 496 hospitalized patients for whom final discharge disposition was available, 122 had a MACE, and 374 did not. Patients who experienced MACE were older (Median Age 63 years with MACE and 58 years with no MACE). Patients who have past medical history of CAD are more likely to have MACE (OR=2.1, 95% CI = 1.1). Elevated NT-pro-BNP (OR= 2.872727, 95% CI = 1.565311), Elevated IL 6 (OR= 5.916667, 95% CI = 2.6538), Elevated Troponin-I (OR= 4.043929, 95% CI = 2.41664) were all independently associated with higher MACE. Race, Gender, Ethnicity, Smoking status, body mass index, prior use of angiotensin receptor blockers, history of hypertension, diabetes, chronic kidney disease were not associated with MACE. SARS-CoV-2 infected patients who develop MACE were 16 times more likely to die during the hospitalization.

Conclusions

Advanced age, history of CAD, elevated NT-pro-BNP, elevated IL-6, elevated Troponin I are all independent predictors of MACE in SARS-CoV-2 infected patients.

Cardiovascular I

76 Cardiac preoperative assessment of vascular surgery patients

K Pasha*

E Levine

E Schultz

A Menon

N Coplan

Lenox Hill Hospital, New York, NY

Purpose of Study

Cardiac preoperative evaluation may be considered in the preoperative assessment of vascular surgery patients. The purpose of this study was to perform a retrospective analysis of how clinicians are utilizing this tool and its effects on preoperative cardiac work up.

Methods Used

We performed a single center retrospective analysis of patients who underwent non-urgent carotid endarterectomy or peripheral bypass surgery over a 12 month period. Patients with a history of myocardial infarction or congestive heart failure exacerbation 30 days prior to surgery were excluded. Inpatient and outpatient preoperative evaluations were included. A result was considered statsitically significant at p<0.05.

Summary of Results

The study included 70 patients (69% male) with mean age of 71.7 (±9.6) years; predominant risk factors included hypertension (94%), hyperlipidemia (89%), and a history of smoking (60%). Forty- three (61%) patients had carotid surgery and 27 (39%) patients had bypass surgery. Forty-four (63%) patients had cardiac evaluation. Compared with patients who did not have cardiac evaluation, there was no significant difference in history of coronary disease (59% vs 42%, p=0.17), heart failure (18 vs 11, p=0.5), diabetes (43 vs 50%, p=0.58), hypertension (93 vs 96%, p=1) or hyperlipidemia (88 vs 88%, p=1). Revisded cardiac index was performed in 9/44 (20.5%) patients and Gupta score was used in 3/44 (7%) patients who had cardiac evaluation; neither score was performed in patients without cardiac evaluation. There was no significant difference in likelihood of having a cardiac evaluation based on type of surgery (p=0.3), but risk score evaluation was more likely performed in patients undergoing bypass surgery (35 vs 5%, p=0.01).

Cardiac evaluation was associated with higher likelihood of getting an echocardiogram (70 vs 46%, p=0.04), EKG stress test (34 vs 8%, p=0.01), and myocardial perfusion stress test (52 vs 15%, p=0.002).

Conclusions

Cardiac preoperative evaluation in patients undergoing vascular surgery results in higher likelihood of cardiac noninvasive testing. Preoperative risk indices are a crucial tool in this population and are significantly underutilized.

77 Assessment of the correlation between carotid artery mean intima-media thickness and brain natriuretic peptide in patients with psoriasis

F Etaee1*

M Shahidi-Dadras2

N Niknezhad2

F Rajabi2

H Haghighat Khah2

N Niknejad3

S Younespour3

T Naguib1

1Texas Tech University Health Sciences Center, Amarillo, TX

2Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

3Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

Purpose of Study

Numerous studies have documented an association between psoriasis and subclinical atherosclerosis. Our aim was to investigate the effects of psoriasis on the levels of N-terminal prohormone B type natriuretic peptide (NT-proBNP) and clarify whether this factor correlates with the evaluation of subclinical atherosclerosis, measured with mean intima-media thickness (MIMT) of carotid artery.

Methods Used

Sixty-one psoriatic patients and sixty-one healthy, age and sex-matched volunteers were enrolled. MIMT was assessed via ultrasonography and serum NT-proBNP level was measured by electrochemiluminescence.

Summary of Results

The median NT-proBNP level was 26.67 (IQR: 15.15–43.03) in patients with psoriasis and 17.45 (IQR: 12.35–20.80) in the control group (P< 0.001). Psoriasis was significantly associated with high NT-proBNP after controlling for the effects of age and gender (adjusted R2=0.24, F=13.40 and p<0.0001). The median NT-proBNP level was 57.98 (IQR: 33.74–91.30) in patients with arthritis and 23.14 (IQR: 14.30–36.31) in patients without arthritis (P= 0.002).

The mean MIMT was significantly higher in patients than control subjects (P<0.0001). MIMT was positively correlated with age and serum NT-proBNP level in both groups. In patients with psoriasis, MIMT also positively correlated with the disease duration (table 1).

Abstract 77 Table 1

Correlation between mean intima-media thickness (MIMT) and all other variables evaluated

Conclusions

NT-proBNP levels correlate with MIMT of the carotid artery and may be used as a predictor for subclinical atherosclerosis in patients with psoriasis.

78 Prognostic value of silent myocardial infarction in patients with chronic kidney disease status post kidney transplantation

J Santana*

H Doppalapudi

CW Ives

D Rizk

V Kumar

AE Iskandrian

FG Hage

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

Patients with advanced kidney disease have an increased cardiovascular disease (CVD) risk. We have previously shown that silent myocardial infarctions (SMIs) are associated with increased CVD risk in patients awaiting renal transplantation (RT) and that screening myocardial perfusion imaging (MPI) provides prognostic data post-RT. We evaluated the prevalence of SMI in patients undergoing RT and its prognostic value after RT.

Methods Used

We identified consecutive patients who underwent RT at UAB between 2008 and 2012. MI was determined by automated analysis of 12-lead ECG obtained at time of RT. SMI was defined as ECG evidence of MI without a history of clinical MI (CMI). The primary outcome was a composite of CVD death, non-fatal MI and coronary revascularization after RT.

Summary of Results

Of the 1189 patients, a 12-lead ECG was available in > 99% (median age 51 years, 56% male, 34% diabetes, 95% hypertension, 83% on dialysis, 60% cadaveric transplant). MI by ECG was present in 13% of the cohort (56% SMI). During a median follow-up of 4.6 years, 147 (12%) experienced the primary outcome (8% CVD death, 4% MI, 4% coronary revascularization) and 12% died. Both SMI and CMI were associated with increased risk of CVD events (figure 1, left panel) and all-cause deaths. In a multivariable adjusted Cox-regression model, both SMI (adjusted hazard ratio 1.99, [1.24–3.20], p=0.004) and CMI (2.13 [1.22–3.70], p=0.007) were independently associated with the primary outcome. In the subset of patients (n=633) who had normal MPI the prognostic significance of SMI and CMI was maintained (figure 1, right panel).

Conclusions

SMI detected by ECG on pre-transplant evaluation is associated with increased risk of CVD events after RT. The risk is maintained even in the subset of patients with normal MPI.

79 THE IMPACT OF PSYCHIATRIC COMORBIDITIES ON THE OUTCOMES OF CONGESTIVE HEART FAILURE

T Sharma1*

K Vellanki1

A Goel1

JL Mehta2

1University of Arkansas for Medical Sciences, Little Rock, AR and

2University of Arkansas for Medical Sciences, Little Rock, AR

Purpose of Study

To study the impact of psychiatric comorbidities on hospital readmissions, healthcare utilization and mortality in patients with congestive heart failure (CHF).

Methods Used

Study population included all patients hospitalized for CHF at a tertiary-care hospital in Southern US from May 2014 to May 2020. ICD-9 codes were used to identify patients with a psychiatric diagnosis (generalized anxiety disorder, specific phobias, post-traumatic stress disorder, mood disorders including major depression and bipolar disorder, schizophrenia, and psychosis) at first hospitalization. Demographic information, readmissions for CHF exacerbation at 30 and 60-day intervals, as well as, mortality during the study period was compared between the two groups.

Summary of Results

Among a total of 5344 patients with CHF, 40.68% (n=2174; 61% females) had a psychiatric comorbidity at first admission. Smoking history was higher in those with a psychiatric diagnosis, however, other health behaviors including alcohol and drug use were not different. Patients with a psychiatric diagnosis had a higher risk of readmission due to CHF exacerbation at 30 days [15.18% vs 10.03%, p<0.001] as well as at 60 days from first admission [21.57% vs14.70%,1.46, p<0.001]. These patients also greater all-cause mortality [31.05% vs 24.42%, RR 1.27, p<0.0001].

Abstract 79 Table 1

Conclusions

Presence of co-morbid psychiatric diagnosis predisposes CHF patients to higher hospital readmissions and mortality.

80 Impact of diabetes and hypertension on left ventricular structure and function in African Americans: the Jackson heart study

A Hamid1*

W Yimer1

AA Oshunbade1

D Kamimura2

D Clark1

ER Fox1

P Munter3

D Shimbo4

A Pandey5

A Shah6

Y Min1

R Mentz7

D Jones1

A Bertoni8

JE Hall1

A Correa1

J Butler1

ME Hall1

1University of Mississippi Medical Center, Jackson, MS

2Yokohama Shiritsu Daigaku Igakubu Daigakuin Igaku Kenkyuka, Yokohama, Japan

3The University of Alabama at Birmingham School of Public Health, Birmingham, AL

4Columbia University, New York, NY

5The University of Texas Southwestern Medical Center, Dallas, TX

6Brigham and Women’s Hospital, Boston, MA

7Duke University, Durham, NC

8Wake Forest University, Winston-Salem, NC

Purpose of Study

Diabetes mellitus (DM) and hypertension (HTN) have been associated with adverse left ventricular (LV) remodeling. However, as DM and HTN often occur concurrently, the independent effects of DM and HTN on LV remodeling have not been adequately assessed.

Methods Used

Jackson Heart Study participants (n=4143 African Americans) at baseline exam with echocardiographic measures were stratified into 4 groups: neither DM nor HTN (n=1643), only DM (n=152), only HTN (n=1669), or both DM and HTN (n=679). Variations in baseline echocardiographic measures of LV structure and function, and brain natriuretic peptide (BNP) levels among these groups were evaluated by multivariable regression adjusting for covariates.

Summary of Results

Mean age of the participants was 52±1 years and 63.7% were women. LV mass index (LVMI) was not significantly different in participants with only DM compared to participants with neither DM nor HTN (p=0.8). LVMI was 7.9% (6.0 g/m2) higher in participants with only HTN and 10.8% (8.1 g/m2) higher in participants with both DM and HTN compared to those with neither (all p<0.001). Similarly, LV wall thickness (relative, posterior, and septal) and BNP levels in participants with only DM were not significantly higher than in participants with neither (all p>0.05). However, participants with both demonstrated significantly higher LV wall thickness and BNP levels than participants with neither (all p<0.05).

Conclusions

In this cross-sectional analysis, DM was not associated with changes in LV structure or function unless participants also had HTN. These data suggest that HTN is the main driver of cardiac structural and functional changes in patients with DM.

Medical Education/Medical Ethics/Advocacy

1:00 PM

Friday, February 26, 2021

81 Predictive factors for specializing in medicine

J Lamar*

The University of Alabama at Birmingham School of Medicine, Huntsville, AL

Purpose of Study

The path to choosing a medical career is complex requiring one to consider personal beliefs, values, past experiences, and future expectations. With a growing shortage of physicians, especially in primary care, determining what influences students to choose a particular medical career can provide insight into any controllable factors that medical schools and residencies can modify to increase primary care physicians. This study investigated the ability to predict an individual’s career choice based on certain predictive factors.

Methods Used

Data was collected via survey from 2003 to 2015 on incoming first year medical students at the University of Alabama at Birmingham School of Medicine. Following graduation, residency match data was collected on the 1351 participants and each categorized into primary care specialty and specialized medicine. The data was analyzed for factors that predicted whether a student would choose primary care or to specialize.

Summary of Results

Out of twelve independent factors, six were statistically significant. Financial incentive, level of expertise, and opportunity to specialize were associated with becoming a specialist. Opportunity to teach, variety in the practice, and interactions with patients were associated with becoming a primary care physician. The model predicted the students who matched in Primary care with 53.1% accuracy and predicted those who specialized with 72% accuracy. The model had an overall accuracy of 63.4%.

Conclusions

Although there are not clear determinants of knowing what career a medical student will ultimately chose, this study highlights six predictive factors to suggest whether an individual has a higher likelihood of entering into primary care or specialized medicine.

82 COVID-19 effects on mental health and well-being of Tulane university school of medicine students

TM Tran

W Provosty

Y Fang*

K Weissbecker

M Myint

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

The COVID-19 pandemic has had a significant effect on the mental health of healthcare workers, but current literature lacks the impact of the pandemic on medical students. This study aims to assess the impact of COVID-19 and social isolation on medical student resilience and burnout.

Methods Used

A REDCap survey created at the University of Chicago was distributed to 21 medical school programs from May 26th to June 22nd, 2020. The survey components included basic demographics and two main questionnaires: Perceived Stress Scale (PSS), Maslach Burnout Inventory - Human Services Scale (MBI). Data from Tulane University School of Medicine (TUSOM) students was specifically analyzed using SPSS version 26. Corresponding z and t tests were run comparing respective normative tables provided by the questionnaire manuals and current literature. ANOVA was run to determine ingroup differences.

Summary of Results

A total of 201 TUSOM students were surveyed across four classes. For PSS, both males (p < 0.001) and females (p < 0.001) displayed greater levels of stress compared to a pre-COVID norm table and TUSOM females were disproportionately more stressed than males (p = 0.007). Across the four classes, an ANOVA showed statistically significant higher perceived stress scores in M2s compared to M1s (p = 0.013). MBI results showed significantly higher exhaustion (p < 0.001) and a lower sense of accomplishment (p < 0.001) when compared to a normative table. Both males (p < 0.001) and females (p < 0.001) scored higher on resiliency than a normative table.

Conclusions

Overall, students were more stressed, and burnt out during the COVID-19 pandemic compared to pre-COVID normative tables provided by each questionnaire’s manual. Programs must be designed to help students through these times of global crises. TUSOM, for one, provided students with counselors and other resources, but more could be done. Future directions should be pursued through a second survey of TUSOM students to compare perceived stress and burnout scores after the pandemic.

83 Impact of an early literacy volunteer program on medical student clinical experience

C Nguyen*

KE Gerth

A Caldwell

M Dunlap

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Purpose of Study

Medical students have limited exposure to pediatric patients and limited education on how to interact with the families of pediatric patients. Reach Out and Read (ROR) is an evidence-based program promoting early literacy. The ROR model includes a volunteer reading program that promotes reading aloud in clinics. Med student volunteers at our institution are trained to model shared-reading to children, interact with and create a stimulating environment for patients and families. This program provides an opportunity to examine the impact of volunteering on clinical interaction skills with pediatric patients and families. This study analyzes the impact of volunteering on various aspects of med student education. We measured knowledge of how to model shared-reading to families, clinical experience, and impact of volunteering on academic career.

Methods Used

145 current med students, both volunteers and non-volunteers, completed an anonymous electronic survey measuring several variables: clinical interaction skills, knowledge of modeling shared-reading, and the impact of volunteering on academic career. Data were stratified by volunteer status. Quantitative and qualitative data were analyzed.

Summary of Results

89.5% of volunteers vs 19.8% of non-volunteers reported knowing how to model shared reading to families (p<.00001). 89.5% of volunteers vs 63.5% of non-volunteers reported feeling comfortable working with families of pediatric patients (p=.02). 94.7% of volunteers agreed that volunteering with ROR impacted their career while in medical school. Student reported being ‘more comfortable in the clinic setting and with families’ and that volunteering ‘reminded me of why I chose medicine and why I am passionate about advocating for children’s health from a biopsychosocial model.’

Conclusions

Participating in the ROR volunteer program is associated with two crucial skills for future pediatricians: interacting with pediatric patient families and modeling shared-reading to families. Involvement also impacts the academic career of med students in meaningful ways. Incorporation of opportunities like the ROR volunteer reading could improve medical student education and clinical skills during their training.

84 Evaluation of a pediatric residency humanities elective

KE Gerth*

C Hester

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Purpose of Study

The purpose of this study is to evaluate the effects of a medical humanities elective course for pediatric residents. Specifically, the study aims to determine if participation in a humanities course affects empathy, cultural competence, patient care, and well-being in pediatric residents. The course will be evaluated through standard post course evaluations as well as broad exploration of the participant’s application of the course throughout their clinical practice via open-ended semi-structured inquiry.

Methods Used

33 pediatric residents completed the course between August 2017 and September 2020. The course consists of a variety of humanities experiences, including literature, art, and music. Weekly debriefing occurs with course directors. Participants complete the standard rotation evaluation for the course. Additionally, a single, one-time survey has been developed and will be sent via Qualtrics October 2020 to previous course participants. The survey aims to investigate the effects of the course on their overall wellbeing and integration of elements of the course into their daily practice.

Summary of Results

Response rate for course evaluations: 100%, n=33, 1/3 male, 2/3 female

Educational goals met: 100%

Scaled Questions: (1–5 with 5 being excellent/best/strongly agree)

Quality of teaching: 4.75 (SD=0.5)

Quality of rotation: 4.42 (SD=0.6)

Rotation promoted an environment of scholarly inquiry: 4.72 (SD=0.4)

Comments included the course was a/an, ‘breath of fresh air,’ ‘opportunity to get rejuvenated,’ ‘good for my mental health,’ ‘lead to deep introspection and growth,’ ‘helps the learner reacquaint themselves with the reasons for going into medicine.’ One learner stated, ‘some version of this course should be mandatory for all students.’

Survey of past participants: results pending; will be available December 2020

Conclusions

Evaluations reveal the course is popular among residents, delivered effectively, and achieves its educational goals. These data suggest the course should continue to be offered and used as a model for future humanities courses at other institutions. We look forward to pending survey results to discover how past participants may be incorporating elements of the course into their personal lives and professional practice.

85 Implementation of a novel leadership skills curriculum for senior pediatric residents

D Mai1*

P Mullan2

P Farrell3

H Newton1

R Kapoor2

1Eastern Virginia Medical School, Norfolk, VA

2Children’s Hospital of The King’s Daughters, Norfolk, VA

3Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Purpose of Study

Although physician leadership is linked to improved health care quality and may decrease burnout, leadership is rarely a focus during residency. We aim to (1) identify leadership skills that senior residents require to effectively function as a leader; (2) develop a leadership curriculum to address the identified needs; and (3) deliver the curriculum in an open forum with peer-to-peer learning.

Methods Used

During the 1st year, focus groups were held with senior pediatric residents to understand their leadership experiences and identify training needs. Notes were recorded and independently coded by 2 researchers, with thematic saturation achieved. In the 2nd year, each session focused on one leadership skill identified to collect more in-depth understanding of their training needs. In the 3rd year and beyond, a formalized curriculum was implemented by facilitating open discussion on each leadership skill and then introducing evidence-based strategies. At the end of each year, an anonymous survey was conducted to inform curricular changes.

Summary of Results

4 major themes were identified: (1) Effective and timely communication is indispensable in promoting safe patient care and avoiding conflict. (2) Training in teaching methods is desired, especially with various levels of learners and different settings. (3) Time management, availability of resources, and team logistics were often learned through trial-and-error. (4) Self-care, self-regulation and peer debriefing are relied upon to manage negative emotions; rarely are coping techniques employed in ‘real-time.’ Feedback from the monthly group sessions was overwhelmingly positive. 27 (61%) of 44 participating residents responded to the survey. 23 (85%) residents found the sessions useful, 4 (15%) were neutral, and none rated the sessions not useful. 26 (96%) reported that the sessions should be continued.

Conclusions

Senior residents currently face gaps in leadership training and may benefit from additional instruction. We have developed a formalized curriculum that delivers leadership training based on identified needs and available evidence. The curriculum will be updated annually based on individual needs, available evidence, and survey feedback.

86 Pediatric provider practices regarding screen time use

E Cahill*

C Garbe

M Dunlap

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Purpose of Study

Nearly 87% of children exceed the recommendations for screen time (ST) use and ST triples from ages 12 months to 3 years, contributing to adverse effects across multiple health domains. Pediatric providers (PPs) are in a unique position to support behavior change; however, there is little research into provider practices in this regard. This study examined PPs’ screen time-management practices and perceptions.

Methods Used

Physicians, residents and mid-level providers in Pediatric and Family Medicine programs and 10 community-based clinics completed an anonymous electronic survey about their ST management practices in pediatric patients. Likert scales quantified responses from 1 (never/strongly disagree) to 5 (always/strongly agree). Responses of 4 and 5 were combined to denote agreement/usual practice. Data were analyzed using descriptive statistics and responses were compared between attendings and residents.

Summary of Results

124 out of 278 PPs completed the survey with 70% assessing ST as part of their practice and 92% promoting limiting ST. However, only 35% assess ST in patients of all ages and 16% report not starting to assess ST until children are older than 2 years old. Only 20% assess online citizenship, 28% access to screen devices, 45% house rules for ST use and 10% parental ST use. Just 40% discuss health consequences of excessive ST use. Most PPs agreed that they have a role in limiting ST use (95%) and that patients are more likely to decrease ST use if counseled by a PP (76%); however, only 46% felt they are effective in counseling patients on ST use, with attendings more confident than residents (p = 0.0066). Less than half of residents (47%) felt they received appropriate training about ST management. The top barriers cited by PPs were time constraints, interest in changing behavior, and difficulty in affecting behavior change.

Conclusions

While most PPs incorporate assessment of ST in their routine practice, many do not assess specific risk factors for excessive screen use and the majority did not feel effective at reducing ST in their patients. PPs cited time, interest, and changing parental behavior as barriers that could be targeted as areas for improvement. With many residents reporting training as a factor, improving residency training may improve efficacy.

Neurology and neurobiology

2:45 PM

Friday, February 26, 2021

87 Transcranial doppler flow assessment for early prediction of brain injury in asphyxiated neonates receiving therapeutic hypothermia

R Lavu*

P Maertens

M Zayek

R Bhat

University of South Alabama, Mobile, AL

Purpose of Study

Early after birth, compensatory cerebral vasodilation and consequent increase in cerebral blood flow to increase cerebral tissue oxygenation prevail in neonates with encephalopathy due to perinatal asphyxia. Hence, neurosonographic Doppler indices to measure cerebrovascular hemodynamics may allow early prediction of adverse neurological outcomes.

Methods Used

In this retrospective, single-center, observational case-control study, neonates born at ≥ 34 weeks’ gestation with a birth weight of > 2000 g, born between January 2012 and December 2019 and received therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy were evaluated for the study inclusion. As per the center’s protocol, transcranial duplex neurosonographic evaluations were performed after the initiation of hypothermia. The transcranial Doppler indices (resistive index, pulsatility index, and peak systolic velocity) of the middle cerebral artery (MCA) and the anterior cerebral (ACA) artery were obtained through the temporal acoustic window. The adverse outcome was defined as death before hospital discharge or abnormal brain magnetic resonance images during the first postnatal week. The predictive ability of Doppler indices of intracranial vessels to predict adverse outcome was assessed using receiver operating characteristic (ROC) curves.

Summary of Results

Out of 70 infants with median (IQR) gestational age and birth weight of 38 (37, 39) weeks and 3223 (2830, 3500) g, respectively, a total of 28 (40%) infants developed adverse outcome. The MCA resistive index at an optimal cut-off value of <0.70 was the best performing Doppler index with an area under ROC curve (95% CI) of 0.68 (0.54–0.82). The predictive accuracy at the optimal cut-off value, as measured by sensitivity, specificity, positive predictive, and negative predictive value with 95% CI, were 57% (37% - 75%), 79% (63% - 90%), 64% (42% - 82%) and 73% (58% - 85%), respectively.

Conclusions

MCA resistive index may serve as a cerebrovascular hemodynamic index for early adverse risk stratification in neonates with HIE treated with hypothermia. If MCA resistive index is used in conjunction with other known clinical-biochemical early biomarkers of brain injury, predictive accuracy may further improve.

88 Somatic mosacism of a single platelet derived growth factor receptor beta variant: the role of allele frequency on phenotype

F El-Ghazali*

M Ferreira

University of Washington, Sammamish, WA

Purpose of Study

Aneurysmal dilatations weaken arterial walls and put them at risk for catastrophic rupture. Germline variants and environmental contributions account for a minority of aneurysms and little is known about the role of somatic events in pathogenesis. Recently, our group described an index patient with a somatic mosaicism pattern of a unique vascular and cutaneous phenotype. Whole exome sequencing of affected vascular tissue revealed an activating somatic variant in platelet derived growth factor beta (PDGFRB) with allele fractions between 2–40%. This variant was absent from matched blood DNA and unaffected tissues from throughout the body. Ten years later, the patient suffered a deadly subarachnoid hemorrhage and the family elected scientific donation. We aimed to study the PDGFRB allele fraction to histopathologic phenotype relationship throughout the patient’s body.

Methods Used

The institutional review board at the University of Washington approved all research conducted. Postmortem tissue specimens along with cell lines were harvested and mirrored tissue specimens were processed for both DNA extraction and histology. A unique digital droplet polymerase chain reaction (ddPCR) assay specific for the PDGFRB variant (p.Tyr562Cys [g.149505130T>C (GRCh37/hg19) was developed to study allele fractions at a 20,000x depth coverage. Obtained allele frequencies were compared to the pathogenic phenotype.

Summary of Results

The patient developed intracranial, radial and coronary artery aneurysms ipsilateral to the cutaneous phenotype. There was no aortic involvement and contralateral vasculature was normal. ddPCR revealed the presence of variant gradient in all affected tissue. Interestingly, the aorta and unaffected arteries did not harbor the variant. We will discuss the allele frequency relationship to phenotype throughout the patient’s vascular tree and tissues.

Conclusions

The PDGFRB variants are associated with both cerebral and coronary aneurysms. The aorta was spared without evidence of aneurysmal changes. This is in contrast to inheritable connective-tissue diseases such as Ehlers-Danlos (vascular type) syndrome and Loeys-Dietz syndrome, where an aortic phenotype is uniform. This is the first described case of a PDGFRB variant - gradient map showcasing somatic mosaicism with a vascular phenotype.

89 Novel fusion of mri signal intensities: a synergistic approach for quantifying patient tumor disease burden

E Florez*

R Hamidi

S Baird

H Khosravi

J Storrs

A Fatemi

University of Mississippi Medical Center, Flowood, MS

Purpose of Study

Magnetic resonance imaging (MRI) of brain tumor is comprised of 14 series of pulsed sequences and each of them needs to be interpreted. Our novel approach fuses meaningful signal characteristics of brain pathology on a limited series of MRI images. In particular, we aim to diminish the impact of nonmaterial biophysical signal changes while improving the conspicuity of true tumor progression to improve its prognostic and diagnostic characterization.

Methods Used

HIPPA-compliant, IRB-approved retrospective posthoc analysis of 45 patients with different biopsy-proven glioma grades were analyzed. Anatomical and functional MRI sequences including fluid-attenuated inversion recovery (FLAIR), T1-weighted without contrast (T1), and T1 after gadolinium administration (T1+C) were analyzed using in-house algorithms. First, the resizing and pre-processing of the volumes were performed. Then, pixel-by-pixel subtraction of T1 from T1+C images was processed to obtain the true enhancement of the intracranial tumor. The T1 subtraction volume (T1S) markedly diminished the conspicuity of hydrated calcium, subacute blood, cortical necrosis, fat, while improving the conspicuity of capillary leakage. Due to the loss of anatomical details on the T1S volume, an adaptive MRI fusion algorithm was used to co-register FLAIR signal intensity on the same-pulsed sequence.

Summary of Results

The resulting fused volume (FUSEDFT) is a novel approach for tumor quantification in which gad-contrasted tumor elements (from T1S) were superimposed on co-registered FLAIR sequences. Thus, the co-localization of true gad contrast with FLAIR hyperintensity can be ascertained for the entire tumor volume. The FUSEDFT volume of patients with various primary brain tumors was calculated before surgical biopsy, after surgical biopsy, and following treatments. Tumor segmentation with respect to surgical cavity, FLAIR abnormality, and enhancement was obtained. Concordance of FUSEDFT and FLAIR volumes was excellent, while FUSEDFT and T1+C were moderate. When FUSEDFT was correlated with T1S concordance was high.

Conclusions

FUSEDFT images appear to be a powerful tool for evaluating the progression of low- and high-grade gliomas following various pharmacologic, biologic, radiation-induced, surgical, and oncological treatments.

90 Regional effects of methadone exposure on oligodendrocyte lineage in the developing rat brain

J Gibson1*

T Chu2

N Mellen1

LA Devlin1

J Cai2

1University of Louisville, Louisville, KY

2Pediatric Research Institute, Louisville, KY

Purpose of Study

Methadone (MTD) is the cornerstone of medication treatment for opioid use disorder (OUD) during pregnancy. Recent studies support the impairment of myelination in the fetal rat brain after antenatal exposure to MTD. The purpose of this study was to investigate the effects of MTD exposure on oligodendrocyte (OL) development in brain of neonatal rats.

Methods Used

6 pregnant Sprague Dawley rat dams were randomized to MTD (0.2 ml/L) or untreated drinking water from embryonic day 7. Treatment group pups continued to receive MTD via maternal milk through postnatal day 7. Pups were then terminated, and coronal sections were harvested from 3 randomly selected pups of each group for immunohistochemistry. The corpus callosum (CC), lateral-CC, and external capsule (EC) were analyzed using ImageJ to quantify myelination (MBP+ fractional area), proliferation rate (fraction of Ki67+-labeled oligodendrocyte precursor cells (OPCs)), apoptosis (density of cleaved caspase 3+ (CC3+) cells co-stained with Pdgfra+, CC1+, or MBP+), and neuroinflammatory status (GFAP+ fractional area; Iba1+ cell density). Comparisons were conducted using student t-test with a significance level p<0.05.

Summary of Results

Myelination was significantly decreased in CC, lateral-CC, and EC of the treatment group. The density of OPCs (Olig2+/Pdgfra+) was significantly increased in CC without significant changes in proliferation or apoptosis. Mature OL density (Olig2+/CC1+) was increased in lateral-CC, but apoptotic ratio was exacerbated in lateral-CC and EC. The apoptosis ratios of myelinating cells (MBP+) were significantly increased in CC, lateral-CC, and EC. Differences in astrocytic activation (GFAP+) were not observed, but microglia (Iba1+) appeared activated.

Conclusions

Our results demonstrate the maturation arrest of OLs in rat pups after antenatal exposure to maternal MTD. This arrest is accompanied by regional microglial activation and accelerated apoptosis of both differentiated and myelinating OLs in different brain white matter regions, suggesting an association between myelin impairment and antenatal opioid exposure.

91 The novel use of a synthetic amino acid analog in management of menkes disease

B Jafar*

A Sheikh

KP Sharma

P Maertens

University of South Alabama, Mobile, AL

Case Report

Menkes disease is a rare X-linked neurodegenerative disorder due to an ATPA7 mutation. This mutation results in a defect in copper transport into the intracellular secretory system. The result is a dysfunction of dopamine beta-hydroxylase, an endoplasmic copper-containing enzyme. Subsequent norepinephrine deficiency causes motor tics and dysautonomia. Here we present the novel use of droxidopa, a synthetic amino acid precursor that acts as a prodrug to norepinephrine in the management of Menkes disease. Our patient is a 5-year-old Caucasian male with a severe deletion in ATPA7gene who has been treated with IV copper supplementations since infancy. At baseline, he is non-verbal, shows no interest in TV, and suffers from dysautonomia with chronic diarrhea and increased secretions. Motor tics are more prominent when seated in an upright position. The patient has periods lasting seconds of increased involuntary movement with arm raising, forearm pronation, neck flexion, facial grimacing, and mouth twitching to the left in a semi rhythmic fashion. EEG is obtained and showed no new findings. Urine norepinephrine is low. After initiating droxidopa titrated to a therapeutic level, repeat urine catecholamine shows the elevation of norepinephrine a month after initiation (table 1), alongside a decrease in motor tics disorder and a new interest in movies. Although copper supplementation and anti-epileptic medication is the mainstay management of the neurological sequelae of Menkes disease, the use of a synthetic amino acid analog should not be overlooked as a form of motor disorder treatment in Menkes disease, which can lead to an improvement in the quality of life. Further investigation is needed to assess the long-term risks and benefits of droxidopa in Menkes disease.

Abstract 91 Table 1

Comparison of 24 hour urine catecholamine levels with amino acid analog dosage

92 Benzodiazepine-responsive catatonia and delirium in two patients with COVID-19

VR Jaber*

M Soliman

JB Campo

EC Mader

Louisiana State University Health Sciences Center, New Orleans, LA

Introduction

About 2/5 of patients with COVID-19 manifest neurological signs and symptoms at the onset of disease, 3/5 at the time of hospitalization, and 4/5 at any time during the course of the disease. Well-recognized neurological manifestations of COVID-19 include delirium and other encephalopathic signs – but not catatonia. We report two patients with COVID-19 who fulfilled the DSM-5 diagnostic criteria for delirium and catatonia.

Case Report

Patient-1 is a 39-year-old male with no history of catatonia or psychiatric disorder and Patient-2 is a 56-year-old female with schizoaffective disorder but no history of catatonia. Both patients presented with delirium, both were admitted to the ICU, and both tested positive for SARS-CoV-2. The neurological examination showed impaired attention and concentration, negativism, muscle rigidity, posturing, and waxy flexibility in both patients. EEG showed evidence of mild encephalopathy in Patient-1 and moderate encephalopathy in Patient-2. Brain MRI was unremarkable in both patients. CSF studies were normal in both patients. In both patients, catatonia and delirium resolved completely with intravenous lorazepam.

Conclusion

If not immediately recognized and treated, catatonia and delirium can lead to significant morbidity or mortality. Unfortunately, catatonia is easily overlooked, especially in patients with delirium. The core motor circuits of the frontal lobe and basal ganglia are the most likely sites of dysfunction in catatonia, but the locus of dysfunction can also be in the circuits of the thalamus, parietal lobe, cerebellum, and limbic cortex. SARS-CoV-2 may have precipitated catatonia by immune-mediated injury or direct invasion of the basal ganglia of Patient-1 and the parietal cortex of Patient-2. The efficacy of benzodiazepines in aborting catatonia and mixed delirium-catatonia syndromes suggests a key pathogenetic role of abnormal GABA neurotransmission in these brain disorders.

Perinatal medicine

2:45 PM

Friday, February 26, 2021

93 Variants of human transcription factor genes in myelomeningocele of Mexican American and European American populations

LS Youmans*

P Hillman

LS Hebert

ME Corkins

R Miller

H Northrup

K Au

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, Houston, TX

Purpose of Study

Identify transcription factor genes with high mutational burdens in individuals of Mexican American and European American populations affected by myelomeningocele. Develop Xenopus (frog) embryo models to reveal the role of identified transcription factors with high mutational burdens in neural tube closure.

Methods Used

We created a Python tool to analyze novel and rare deleterious variants present in transcription factor genes from the exomes of 511 patients with myelomeningoceles. Approximately, half are Mexican Americans and the other half are European Americans. Population control variants were extracted from the Genome Aggregation Database. Variants having a Combined Annotation Dependent Depletion score ≥20 were defined as deleterious. Fisher exact was used to test mutational burden of deleterious variants per transcription factor gene. Knockdowns of transcription factor genes with a high significance have been tested in the Xenopus embryo model.

Summary of Results

We tested 1,639 known human transcription factor genes and found one common gene of significance, ZNF592, in both Mexican American and European American myelomeningocele groups. An additional 36 genes were found to have a possible significant effect in the Mexican American group and 34 genes in the European American group (p < 0.05). Some of these genes are associated with human and mouse diseases affecting the central nervous system. We used morpholinos to knockdown Znf592 in Xenopus embryos. Preliminary results indicated that Znf592 morpholinos did not result in gross abnormality of neural tube formation or a delay of the neurulation process.

Conclusions

High mutational burdens in 71 genes were associated with myelomeningocele in Mexican American and European American. Interestingly, ZNF592 is associated with both ethnicities. Although Znf592 knockdown did not result in significant gross abnormality in the Xenopus embryo, it may play an important role in neural tube formation. Studies to assess the efficiency of Znf592 knockdown using this morpholino are underway. Additionally, we are planning to knockdown Alx1 and Arnt in Xenopus embryos which showed neural tube defect phenotype in mouse models.

94 Intranasal insulin reduced hypoxia-ischemia-iinduced sensorimotor behvaorial dysfunction and brain injury in P5 rats

CK Glendye*

JW Lee

E White

N Dankhara

S Lu

N Ojeda

Y Pang

AJ Bhatt

L Fan

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

Because only supportive therapy is available for premature infants <36 weeks of gestation with hypoxic-ischemic (HI) encephalopathy, there is an urgent need for therapies to improve their outcomes. Intranasal administration of insulin (InInsulin) provides neuroprotection against HI-induced brain injury in postnatal day 10 (P10) neonatal rats. The current study’s objective is to examine whether InInsulin provides protection against brain injury and sensorimotor behavioral dysfunction following HI in P5 rats, which corresponds to the brain development stage of premature Infants.

Methods Used

At P5, Sprague-Dawley rat pups were randomly divided into groups: Sham+Vehicle, Sham+Insulin, HI+Vehicle, and HI+Insulin. The male and female ratio was kept equal. Pups had HI by permanent ligation of the right carotid artery followed by 90 min of hypoxia exposure or Sham surgery followed by room air exposure; immediately after, were given Insulin (25 μg) or vehicle (2.5 μl) in each nare. Sensorimotor neurobehavioral tests and brain injury evaluation by stereology technique following Nissl staining were performed on P6 in a double-blind manner. Statistical analysis was performed via two-way ANOVA followed by the Student-Newman-Keuls method. The sample size was estimated using power analysis to obtain a difference of 30% between means with a power of 85% and a significance of p < 0.05.

Summary of Results

ELISA results demonstrated measurable insulin levels in the brain’s different regions following 15 min after InInsulin administration (p<0.05). InInsulin did not cause hypoglycemia after HI. InInsulin provided the protective effects against HI-induced brain damage measured at P6. InInsulin also attenuated HI-induced sensorimotor neurobehavioral disturbances in righting reflex, negative geotaxis, hind-limb suspension test, and wire-hanging maneuver test at P6 (p<0.05); (n = 4/sex/groups/all results).

Conclusions

The intranasal route effectively delivers human insulin to the brain in P5 rats. InInsulin reduced HI-induced brain damage and short-term sensorimotor behavioral disturbances in P5 neonatal rats. Our preliminary results indicate prospects for Ininsulin as a novel and only therapeutic option against neonatal HI in premature infants.

95 WNT and growth factor RNA expression in the umbilical cord of myelomeningocele affected pregnancies

KM Kuehn*

LS Hebert

R Papanna

LK Mann

H Northrup

K Au

University of Texas Health Science Center Houston-MGovern Medical School, Houston, TX

Purpose of Study

Disrupted neural tube closure results in defects ranging from lethal anencephaly to survivable forms of spina bifida (SB). Myelomeningocele (MM) is the most common form of SB and results in lifelong motor and sensory defects. Research efforts have pointed towards a multifactorial cause with a strong genetic influence. While animal and epidemiologic studies have supported this theory, human studies have been difficult to conduct. Our study aimed to look at differences in expressed genes between the umbilical cord (UC) samples of pregnancies affected by MM compared to controls in order to apply current knowledge to a human model.

Methods Used

UC samples were obtained from three MM affected and five control pregnancies. RNA was extracted and sequenced. Results were filtered to include genes with a false discovery rate <0.05 and at least a 4-fold difference in expression. A gene ontology analysis was performed on the differentially expressed genes to determine functional significance. Ten genes of interest were identified to verify the level of expression by qPCR.

Summary of Results

Overall, 3,748 genes passed the selection criteria. Of these, 49 were involved in WNT signaling or growth factor signaling. Genes involved in both WNT signaling and insulin like growth factor pathways trended towards upregulation, while those genes involved in other growth factor signaling tended to be downregulated. Upon sub-analysis of the genes involved in WNT signaling, those involved in the canonical pathway had the greatest degree of up regulation, followed by those involved in the non-canonical pathway.

Conclusions

Neural tube closure has long been suspected to be reliant on an intricate interaction of multiple genes to proceed correctly. The WNT signaling pathway and growth factor pathways have been implicated in this process. However, much of this information has arisen from either animal or epidemiological based studies. Our study contributes to the understanding of the role these genes play in neural tube defects by showing derangement in expression of mRNAs between the pregnancies affected by MM and controls.

96 Pulmonary microbial dysbiosis leads to redox imbalance through the NRF2 pathway in neonatal murine models

A Freeman1*

K Dolma2

G Rezonzew1

B Halloran1

L Qiao1

TE Tipple3

CV Lal1

1University of Alabama at Birmingham, Birmingham, AL

2University of South Alabama, Mobile, AL

3University of Oklahoma, Oklahoma City, OK

Purpose of Study

Distinct airway microbial dysbiosis is seen in infants with severe bronchopulmonary dysplasia (BPD). In addition to dysbiosis, oxidative stress has been shown to exacerbate BPD, and upregulation of nuclear factor erythroid 2-related factor 2 (Nrf2)-dependent antioxidants are protective. Previous studies revealed protected lung structure and function in germ free (GF) mice. In order to understand the protective mechanisms in GF mice, we analyzed Nrf2 dependent genes heme-oxygenase-1 (Hmox1) and NADPH quinone oxidoreducase-1 (Nqo1), which both neutralize reactive oxygen species and maintain redox balance. In addition, we analyzed pulmonary mechanics in an Nrf2 knockout murine model after colonization with E. coli, respiratory probiotic, or E. coli followed by respiratory probiotic.

Methods Used

GF mice were intranasally inoculated with three separate doses of E. coli at P3, P6, and P9. Phosphate buffered saline (PBS) treated GF mice as well as non-germ free mice (NGF) were used as controls. All groups were exposed to normoxia (21% FiO2) or hyperoxia (85% FiO2). The expression of Hmox1 and Nqo1 in lung tissue harvested at P14 was measured by qPCR.

C57BL/6 mice with an Nrf2 knockout were colonized through intranasal inoculation with PBS, E. coli, respiratory probiotic, or E. coli followed by respiratory probiotic on P3, P6, and P9. All groups were exposed to normoxia (21% FiO2) or hyperoxia (85% FiO2). On P14, pulmonary function tests were performed.

Summary of Results

GF mice colonized with E. coli showed a significant increase in Hmox1 and Nqo1 expression independent of hyperoxia exposure. In an Nrf2 knockout model, treatment with E. coli resulted in worsening pulmonary function in both normoxia and hyperoxia (high resistance P<0.001, low compliance). Treatment with a respiratory probiotic resulted in improvement in pulmonary function even in hyperoxic conditions (decreased resistance P<0.05, increased compliance).

Conclusions

Our results suggest the presence of an interaction between airway microbiome and Nrf2-dependent antioxidant responses in the lung. Through these studies, we hope to lay the foundation for microbiome related therapeutics development for BPD.

97 A human milk diet with higher protein content to increase fat-free mass accretion in extremely preterm infants: a randomized trial

AA Salas*

ML Jerome

A Finck

J Razzaghy

P Chandler-Laney

WA Carlo

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

Hospital-based nutritional interventions should optimize not only quantitative outcomes of growth (i.e., weight gain) but also qualitative outcomes of growth (i.e., body composition). Higher than usual protein intake could increase weight gain, increase fat-free mass (FFM), and decrease fat mass (FM) in extremely preterm infants. We hypothesized that higher protein intake compared to usual protein intake increases FFM and reduces percent body fat (%BF) in extremely preterm infants fed human milk.

Methods Used

This was a single-center, masked, randomized trial in which human milk-fed infants with gestational ages 25 weeks 0 days through 28 weeks 6 days were randomly assigned in a 1:1 allocation ratio to either standard protein supplementation (control group) or high protein supplementation (intervention group) after reaching full enteral feeding. To increase the protein content of human milk in the intervention group, we added a fixed amount of commercially available hydrolyzed bovine protein to fortified human milk (0.8 g per each 100 ml). The study intervention began after human milk fortification was ordered and continued for a minimum of 21 days.

Summary of Results

Fifty-six infants were randomized. The median gestational age at birth was 27 weeks (IQR: 26–28 weeks). Baseline characteristics did not differ between groups. All study participants received either mother’s milk or donor milk. The outcome of% BF at term corrected age or discharge (whichever occurred first) differed between groups (mean difference favoring the high protein supplementation group: +2; 95% CI: 1 to 4; p <0.05). At term corrected age or discharge, FFM Z-scores (-0.9 vs. -1.5; p=0.04) and FM Z-scores (3.1 vs. 2.1; p=0.05) were higher in the intervention group. Weight-Z scores at term corrected age or discharge were also higher in the intervention group (-0.4 vs. -1.2; p<0.05). The secondary outcomes of%BF Z-scores (2.7 vs. 2.3; p=0.21), postnatal growth restriction (19% vs. 32%; p=0.32), and weight gain at term corrected age or discharge (14 vs. 13; p=0.56) did not differ between groups.

Conclusions

Human milk diets with higher protein content increase weight, FFM, and FM Z-scores at term corrected age in extremely preterm infants.

98 Heart rate variability during feeding infants with bronchopulmonary dysplasia

EW Reynolds1*

TM Boles2

C Bell1

1University of Texas, Health Science Center @ Houston, Houston, TX

2Rice University, Houston, TX

Purpose of Study

This study will describe heart rate variability (HRV) during feeding in infants with bronchopulmonary dysplasia (BPD) and determine if a speech therapy intervention can correct autonomic dysfunction.

Methods Used

ECGs were collected during bottle feeding for 25 Low-Risk Preterm (LRP) infants and babies with BPD who were randomized (25 each) to receive a speech therapy intervention (BPDwTX) or standard care (BPDnTX). Heart rate (HR), mean RR interval (RR), standard deviation of consecutive RR intervals (SDRR), and standard deviation of the difference between consecutive RR intervals (SDDRR) were calculated for each. ECGs were converted to power spectra to measure low frequency (LF) and high frequency (HF) power. Independent variables were gestational age (GA), birthweight (BW), postmenstrual age (PMA), weeks before first oral feed (WBFN) and weeks post first oral feed (WPFN). Generalized estimating equations were fit to describe each group.

Summary of Results

LRP infants had larger BW and GA. BPD infants had greater WBFN. There were no associations for HR, RR, LF, HF or LF/HF. SDRR is larger in the BPD groups. SDRR increases with GA. There were no differences for SDDRR among groups. SDRR and SDDRR were correlated. In almost all cases, the results in BPDwTX were closer to the LRP than BPDnTX.

Abstract 98 Table 1

HRV in LRP and BPD

Conclusions

SDRR is increased in BPD. The balanced increase in SDRR and SDDRR suggests that altered respiration in BPD impinges on suck-swallow-breath integration and causes stress during feeding. Our speech therapy intervention may have had a small but irrelevant effect on the stress experienced by the infants during feeding.

Pulmonary and critical care

4:45 PM

Friday, February 26, 2021

99 Metabolomics of asthma: a systematic review

Z Cheema*

SB Mustafa

D Moses

M Evans

A Moreira

The University of Texas Health Science Center at San Antonio, San Antonio, TX

Purpose of Study

Assess metabolomic changes in asthmatic patients.

Methods Used

Five databases were searched to identify studies evaluating metabolomic changes in childhood-onset asthma. Studies that utilized metabolomic profiling via chromatography, mass spectrometry, or magnetic resonance were included. Citation titles and abstracts from literature search and review articles were uploaded to Rayyan. Three investigators independently reviewed and selected studies meeting inclusion criteria. Study characteristics included patient demographics, sample types, method of analysis, and significant metabolite changes. Metabolites were categorized to pathways using MetScape. Semiquantitative analysis via vote counting was used to identify common pathway changes among asthmatic patients.

Summary of Results

Thirty-one studies were identified (n=5742 patients), with individuals ranging from 1–77 years of age. The majority of studies examined exhaled breath condensate (EBC, n=17 studies) via untargeted analysis followed by serum (n=7 studies), urine (n=6 studies), and stool (n=1 study). Four-hundred metabolites were identified and categorized into 18 pathways. The most common pathways were lipid/fatty acid metabolism, amino acid metabolism, and inflammation, all of which were elevated in asthmatic patients. Upregulation of lipid/fatty acid metabolism was reflected in all tissue sources, except stool. Amino acid metabolism was increased in urine and serum samples but downregulated in EBC and stool specimens. The inflammatory pathway had the most significant upregulation in EBC.

Conclusions

Metabolomic profiling may lead to a better understanding of the underlying mechanisms associated with asthma. Herein, we demonstrate that lipid/fatty acid metabolism, amino acid metabolism, and inflammation are key features in asthmatics. Validation of these findings may aid in asthma diagnosis or monitoring of therapeutic management. Future studies should focus on determining the optimal tissue source for greatest accuracy in metabolomic analysis in asthmatic patients.

100 COVID-19 and blood type in Atlanta

M Kaalla1,2*

V Sueblinvong1

A Mehta1,3

1Emory University, Atlanta, GA

2Mercer University, Macon, GA

3Atlanta VA Medical Center, Decatur, GA

Purpose of Study

The purpose of this study was to determine if there are any associations with severity of illness from COVID-19 and ABO blood group among a cohort of critically ill patients across the Emory Healthcare System. Since COVID-19 was first identified, there have been some reports of an association between blood type A and a higher risk of infection and mortality, while other groups have determined that no such association exists. We sought to determine if ABO blood group was associated with higher rates of intubation, mortality, or inflammatory markers at our institution.

Methods Used

We reviewed data from the electronic medical record of all patients who were admitted to the hospital with COVID-19 at any of the Emory Hospitals between March 6, 2020 and May 5, 2020. The data were collected by the Emory COVID-19 Quality and Clinical Research Collaborative, and we analyzed data from patients who had info for blood group and spent any time in the intensive care unit during their hospitalization. We used the Chi-square test to determine if death or intubation were associated with blood group and ANOVA when comparing inflammatory markers between the blood groups.

Summary of Results

A total of 192 patients had data available for blood type, and among them 47 patients had blood group A (24.5% vs 42.0% nationally), 48 had blood group B (25.0% vs 10.0% nationally), 9 had blood group AB (4.7% vs 4% nationally), and 88 had blood group O (45.8% vs 44.0% nationally). Overall death rate (30.2%) and intubation rate (77.1%) were not associated with any blood group type (p=0.424 and p=0.144, respectively). Values for inflammatory markers (CRP, IL-6, D-dimer, WBC, and ferritin) were not significantly different between the different blood groups (p=0.654, p=0.357, p=0.060, p=0.083, and p=0.706, respectively).

Conclusions

When compared to data from the American Red Cross, blood group B was more prevalent and blood group A was less prevalent in our cohort compared to the general population of the US. There was no association between blood group type and death or mechanical ventilation. We noted a trend towards higher D-dimer levels and WBC counts in patients with blood group B, but overall, there were no significant differences between inflammatory markers and blood group types among critically ill patients with COVID-19.

101 COVID-19 and obesity in Atlanta

WA Neveu1*

V Sueblinvong1

A Mehta1,2

1Emory University, Atlanta, GA

2Atlanta VA Medical Center, Decatur, GA

Purpose of Study

Obesity is a complex disease that exhibits alteration in immune function. As the body mass index (BMI) increases, the visceral adipocytes have been found to secrete higher levels of pro-inflammatory cytokines, which contribute to alterations in coagulation signaling. These findings raise concerns that obesity-mediated inflammation may be responsible for the observed findings of higher risk of severity from SARS-CoV-2. This study examines the effect of obesity on levels of inflammatory markers and severity of illness from COVID-19 in a cohort of critically ill patients.

Methods Used

Data were collected from the electronic medical record by the Emory COVID-19 Quality and Clinical Research Collaborative. We analyzed data of patients admitted with COVID-19 within the Emory Healthcare System between March 6, 2020 and May 5, 2020 who spent time in the ICU during their hospitalization. We used the Chi-square test to determine if death or intubation were associated with obesity (BMI > 30) and t-tests when comparing inflammatory markers between obese and non-obese patients. Multivariate logistic regression was completed to evaluate the role of BMI as a continuous variable, severity of illness, and age on death.

Summary of Results

Results for BMI were available for 285 patients, among which 149 patients (52.3%) were considered obese with a BMI of 30 or greater. Obese patients in our cohort were younger on average by 10 years (59 years vs. 69 years, p<0.0001), and there was no significant difference in gender. Intubation rates were significantly higher in the obese population (80.5% vs. 64.7%, p=0.0026), and death rates were significantly lower in this group with a BMI greater than 30 (26.2% vs. 43.4%, p=0.0022). Inflammatory markers (CRP, IL-6, D-dimer, and WBC) were not significantly different between obese and non-obese individuals. Multivariate logistic regression analysis determined that BMI (numerical value) was a significant negative predictor for death when controlled for severity of illness as indicated by sequential organ failure assessment score and age (OR 0.94, 95% CI 0.90–0.98, p=0.0014).

Conclusions

In our cohort of critically ill patients with COVID-19, obesity is associated with a greater risk of mechanical ventilation, but a lower risk of death even when accounting for severity of illness and age.

Acknowledgement

Funding from Georgia CTSA (UL1TR002378).

102 Alcohol impairs alveolar macrophages responses to mycobacterium tuberculosis

L Sayegh*

M Ahmed

X Fan

SC Auld

D Guidot

BS Staitieh

Emory University School of Medicine, Atlanta, GA

Purpose of Study

Chronic alcohol ingestion has been associated with increased rates of pulmonary tuberculosis and is known to impair alveolar macrophage (AM) innate immune function against bacterial pneumonia. Because the AM is an essential component of the initial immune response to Mycobacterium tuberculosis (Mtb), we hypothesized that alcohol impairs key pathways in the innate immune response to Mtb as well. We therefore performed a series of experiments to investigate the effects of chronic alcohol exposure on pathways important for the recognition, phagocytosis, and killing of Mtb.

Methods Used

Chronic alcohol ingestion has been associated with increased rates of pulmonary tuberculosis and is known to impair alveolar macrophage (AM) innate immune function against bacterial pneumonia. Because the AM is an essential component of the initial immune response to Mycobacterium tuberculosis (Mtb), we hypothesized that alcohol impairs key pathways in the innate immune response to Mtb as well. We therefore performed a series of experiments to investigate the effects of chronic alcohol exposure on pathways important for the recognition, phagocytosis, and killing of Mtb.

Summary of Results

In NR8383 cells, TLR2, CD14, and TNFa gene expression in response to Mtb was blunted in cells exposed to alcohol. Rat AM expression of GM-CSF-R-β, Mannose receptor, and TLR2 were also impaired by chronic alcohol exposure. Although expression of all three proteins was enhanced by exposure to Mtb in rat AMs, alcohol blunted the response significantly relative to macrophages from control-fed littermates.

Conclusions

In a rat AM cell line, alcohol exposure impaired expression of genes important to myriad aspects of the Mtb response, including recognition (TLR2), uptake (CD14), and adaptive immune activation (TNFa). Similarly, AMs from alcohol-fed rats demonstrated defects in GM-CSF-R-β, Mannose receptor, and TLR2, all of which are cell surface receptors essential for the recognition and immunre response against Mtb. Further studies are needed to better detail the full extent of alcohol’s effects on the Mtb response, but these data suggest that those defects occur in a variety of important cellular pathways.

103 Blood transcriptome enriched with megakaryocyte gene signature predicts poor outcome in idiopathic pulmonary fibrosis (IPF)

S Saito*

CH Chung

N Nuradin

Y Liu

J Lasky

J Kolls

Tulane University, New Orleans, LA

Purpose of Study

A recent study in mice suggested that platelet-releasing megakaryocytes reside in lung interstitium and that the lung is a site of platelet biogenesis. The presence of magakaryocytes in the lungs have also been reported in human. However, the role of megakaryocytes and platelets in idiopathic pulmonary fibrosis (IPF) is ill-defined. We sought to investigate whether megakaryocyte/platelet gene signature is altered in lung and/or blood transcriptome in IPF.

Methods Used

Lung and blood transcriptome data of IPF patients and their controls in the NCBI Gene Expression Omnibus (GEO) repository were analyzed (GSE47460, GSE93606). Enrichment of magakaryocytes and platelets in IPF and the control were estimated using xCell, a novel computational method that assesses enrichment of individual cell types based on gene expression profile. We first compared enrichment scores for each cell type in IPF and the control, using t-test or Kruskal-Wallis test. With regard to blood transcriptome of IPF patients, we also compared the disease progression-free survival (i.e., survival without significant [>10%] decline in forced lung capacity [FVC]) over 6 months, between patients with high megakaryocyte enrichment score and patients with low megakaryocyte enrichment score, using log-rank test. A p-value <0.05 was considered statistically significant.

Summary of Results

In the lung transcriptome data, a megakaryocyte gene signature was less enriched in IPF than in the control group. On the other hand, in the blood transcriptome data, a megakaryocyte gene signature was more enriched in IPF than in the control group. Moreover, IPF patients with higher megakaryocyte score (above median) in blood transcriptome had worse disease progression-free survival than IPF patients with lower megakaryocyte score (below median) (log rank test p=0.0096). There was no significant difference in platelet enrichment scores between IPF and the control group in lung or blood.

Conclusions

In IPF, a megakaryocyte gene signature is altered in the lung and blood transcriptome. Moreover, blood transcriptome enriched with the megakaryocyte gene signature predicts poor outcome in IPF. These data suggest that a megakaryocyte gene signature in peripheral blood may be a novel biomarker in IPF.

104 Use of oral anti-diabetic drugs and risk of hospital and intensive care unit admission for infections

JG Rim1*

J Gallini2

C Jasien2

X Cui1,2

L Phillips1,2

A Trammell1

R Sadikot1,2

1Emory University, Atlanta, GA

2Atlanta VA Medical Center, Decatur, GA

Purpose of Study

Sepsis is one of the top causes of ICU mortality, and diabetes is a risk factor for infections. While metformin has been associated with decreased rates of sepsis, the risk of infections in diabetic patients taking newer classes of oral anti-diabetic drugs (OADs) is uncertain. The aim of our study is to examine the association between outpatient OAD use and hospital admissions for infections.

Methods Used

This is a retrospective data analysis utilizing the VA Corporate Data Warehouse. We identified diabetic patients over 18 years old with diabetes who filled at least 1 OAD prescription from 2013–2017. Patients were classified as taking metformin, sulfonylureas, alpha-glucosidase inhibitors, meglitinides, thiazolidinediones, DPP4 inhibitors, or SGLT2 inhibitors at any point during the study period regardless of admission date. The endpoint was a hospital admission with an infectious condition on the admission or discharge diagnosis list. Multivariate logistic regression was used to estimate the effect of each drug class on admission while adjusting for covariates.

Summary of Results

The cohort included 1.39 million patients with diabetes who were 95.8% male, 72.2% White, 20.3% smokers, and had a mean age of 70.5 years. Of those admitted to a hospital for infection, 7.5% required ICU level of care. After adjusting for covariates, those who took metformin during the study period had 3.3% lower odds of hospital admission for infection compared to those who were never on metformin (OR 0.97, 95% CI 0.95–0.98). OADs that were associated with a statistically significant increased odds of being admitted included meglitinides (OR 1.22, 95% CI 1.07–1.38), SGLT2 inhibitors (OR 1.16, 95% CI 1.08–1.24), alpha-glucosidase inhibitors (OR 1.09, 95% CI 1.04–1.15), and DPP4 inhibitors (OR 1.04, 95% CI 1.01–1.06).

Conclusions

Metformin was associated with lower odds of admission for infection while meglitinides, SGLT2 inhibitors, alpha-glucosidase inhibitors, and DPP4 inhibitors were associated with higher odds of admission. The effect size for most OADs was small with likely limited clinical relevance to individual patients. However, as OADs are widely prescribed, there could be implications at a population level.

Renal, electrolyte and hypertension

4:30 PM

Friday, February 26, 2021

105 Tumor necrosis factor-alpha type-1 receptor protein decreases in renal cortex, not in medulla during high salt intake in nitric oxide deficient mice

DA Majid*

C Osuji

S Talwar

A Abdel-Mageed

A Castillo

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Tumor necrosis factor-alpha (TNFα) is a pro-inflammatory cytokine that is involved in renal injury associated with salt-sensitive hypertension (SSH). In the kidney, TNFα receptor type 1 (TNFR1) activation induces natriuresis, suggesting its’ counter-regulatory role in SSH opposing salt retention. We hypothesize that TNFR1 activity in the kidney is reduced in nitric oxide (NO) deficient condition to induce SSH.

Methods Used

Experiments were performed in intact (C57BL6 strain) and in 2 models of NO deficient mice: a) chronically treated with NO synthase inhibitor, nitro-L-arginine methyl ester (L-NAME; 0.05 mg/min/g by osmotic mini-pump), b) eNOS knockout (KO) mice, which were given normal (NS; 0.4% NaCl) or HS (4% NaCl) diet for 4 weeks (n=6–7 in each group). Systemic blood pressure (SBP) was measured using tail-cuff plethysmography. The kidneys were isolated and processed for tissue analysis at the end of the experiment. The TNFR1 protein in renal (cortical and medullary) tissues was analyzed using the Western blot technique using appropriate TNFR1 and GAPDH antibodies. The blot image was quantified with Image J software.

Summary of Results

HS intake alone did not alter SBP in intact mice (NS, 76 ±2.1 vs HS, 78 ±1.4 mmHg) but increased in L-NAME treated (104 ±2.8 mmHg) and in eNOSKO mice (107±3.6 mmHg). The quantitative immunoblot analysis showed that TNFR1 protein level (band intensity density units) was lower in renal cortical (44±9 vs 111±30 units; P<0.05) but not in medullary tissues (114±16 vs 128±97 units; P=ns) in L-NAME treated mice compared to control mice with HS intake. The intensity of TNFR1 immunoblot was also significantly lower in cortical (24 ± 5 units; P<0.05) but not in medullary tissues (74 ±21 units; P=ns) of eNOSKO mice compared to control mice.

Conclusions

These data indicate that TNFR1 activity is downregulated in renal cortex during HS intake in NO deficient condition. Such downregulation of TNFR1 activity would facilitate sodium retension by the renal cortical tubules leading to develop SSH in NO deficient conditions.

106 Increased glomerular capillary wall strain precedes glomerulopathy in the diabetic rat

O Richfield1,2*

R Cortez1

L Navar1

1Tulane University, New Orleans, LA

2Tulane University School of Science and Engineering, New Orleans, LA

Purpose of Study

Mechanical strain deleteriously affects glomerular cells, causing podocyte hypertrophy and increased deposition of extracellular matrix proteins by mesangial cells. Since these behaviors are concomitant with glomerular hypertension and hyperfiltration in diabetic glomerulopathy, we hypothesized that glomerular capillary wall strain plays a role in the cause and/or progression of glomerulosclerosis in diabetes. However, the magnitudes of glomerular capillary wall strain in diabetic and healthy conditions have yet to be rigorously quantified.

Methods Used

We developed an anatomically accurate mathematical model of blood flow and filtration in a compliant rat glomerular capillary network that estimates the change in glomerular capillary diameter as a function of intraglomerular pressure. We used data from a previous study (Cortes, Pedro, et al. Kidney international 51.1 (1997): 57–68) to estimate the glomerular capillary wall elastic modulus, measured in megapascals (MPa) and defined as the stress required to double the glomerular capillary diameter. We then quantified the strain of the glomerular capillaries in response to alterations in glomerular pressure over the base case (Navar, L.G., et al. Physiology of Membrane Disorders, 1986, pp.637–667).

Summary of Results

Our model predicted that the glomerular capillary wall elastic modulus is significantly reduced early on in diabetes, from 6.7 MPa in control to 1.6 MPa four days post-STZ injection. The elastic modulus then increases to 7.5 MPa five weeks post-injection. These elastic moduli corresponded to median glomerular capillary wall strains of 0.6%, 2.5% and 0.5%, respectively. Furthermore, our model predicted that in early diabetes the highest wall strains of 8% are concentrated in the capillaries branching off of the afferent arteriole.

Conclusions

The magnitudes of glomerular capillary wall strain predicted by our model, especially for the capillaries closest to the afferent arteriole, equaled or exceeded strains that have been shown to deleteriously affect podocytes and mesangial cells in vitro. These findings indicate that mechanical strain may play a significant role in the development of glomerular injury in diabetes.

107 Proximal tubule-specific deletion of mitochondrial protein sirtuin 3 in the kidney attenuates angiotensin II-induced hypertension and augments natriuretic responses in female mice

AO Leite*

XC Li

JL Zhuo

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Sirtuin 3 (SIRT3) is a mitochondrial matrix protein closely involved in energy production and oxidative stress responses in hypertension and kidney diseases. The present study determined the role of SIRT3 in the development of ANG II-induced hypertension using female mice with proximal tubule-specific knockout of SIRT3 (PT-SIRT3-/-).

Methods Used

Adult female wild-type C57BL/6J mice and PT-SIRT3-/- mice (n=6 per group) were infused with or without a slow pressor dose of ANG II via an osmotic minipump (0.5 mg/kg/day, i.p.), supplemented with 2% NaCl diet, to slowly increase blood pressure for 2 weeks. Systolic, diastolic, and mean arterial blood pressure were determined with the tail-cuff method, and 24 h urinary sodium, potassium and chloride excretion were determined using a metabolic cage.

Summary of Results

Basal systolic (SBP), diastolic (DBP), and mean arterial blood pressure (MAP) were significantly lower in adult female PT-SIRT3-/- mice than female wild-type C57BL/6J mice (WT-SBP: 112 ± 2 mmHg vs. PT-SIRT3-/-+SBP: 93 ± 2 mmHg, P<0.01). In response to ANG II infusion and 2% high salt treatment, SBP was increased to 148 ± 6 mmHg in adult femle wild-type mice (P<0.01), but SBP was increased only to 130 ± 7 mmHg in adult female PT-SIRT3-/- mice (P<0.01). There were no significant differences in DBP and MAP responses between female wild-type and PT-SIRT3-/- mice (n.s.). Basal heart rate was not significantly different between adult female wild-type and PT-SIRT3-/- mice (n.s.), but it was decreased to a similar extent in response to ANG II and 2% high salt treatment (n.s.). With respect to basal 24 urinary sodium, potassium, and chloride excretion, no significant differences were observed between wild-type and PT-SIRT3-/- mice (n.s.). However, ANG II and 2% salt treatment significantly augmented 24 h urinary sodium, potassium and chloride excretion in adult female PT-SIRT3-/- mice (P<0.01), compared with female wild-type mice (P<0.01).

Conclusions

Taken together, the present study suggest that SIRT3 in the mitochondria of the proximal tubules may play an important roles in the development of ANG II-dependent hypertension in female mice.

108 Risk of acute kidney injury in covid-19 is increased in african americans with apol1 high-risk genotype

T Wickman1*

J Velez1

L Matute1

J Arthur2

C Larsen3

1Ochsner Health System, Metairie, LA

2University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR

3Arkana Laboratories, Little Rock, AR

Purpose of Study

It has been recently shown that individuals of African American (AA) ancestry who are carriers of the high-risk apolipoprotein L1 (APOL1) genotype are at risk of developing acute kidney injury (AKI) and nephrotic-range proteinuria due to collapsing glomerulopathy when they acquire COVID-19. Nonetheless, the majority of cases of AKI in AAs are due to acute tubular injury. Currently, it is not known whether high-risk APOL1 genotype confers AAs a greater overall risk for AKI due to COVID-19. We hypothesized that the overall risk for AKI is increased in AA carriers of the APOL1 high-risk genotype.

Methods Used

We prospectively identify AA patients admitted at Ochsner Medical Center with a nasopharyngeal swab specimen positive PCR for SARS-CoV-2 RNA. Blood samples were retrieved within 72 hrs of collection and sent to Arkana Laboratories for genotyping for APOL1 polymorphism. Outcome measures were AKI stage ≥ 2 (by KDIGO) and persistent AKI (no resolution by 72 hours) that occurred within 21 days of the positive PCR.

Summary of Results

Specimens from 104 patients were obtained and assayed. Median age was 60 (23 – 92) years, 42% were women, 67% had hypertension and 19% had preexisting chronic kidney disease. The incidence of high risk APOL1 genotype in the entire cohort was 15%, similar to the published prevalence of 14%. Among patients with high risk APOL1 genotype (2 alleles) (n = 16), 11 developed AKI and 5 did not. Among those without high risk APOL1 genotype (0–1 alleles) (n = 88), 32 developed AKI and 56 did not. Relative risk (RR) for AKI was 1.89 (1.23–2.90), p=0.004. Similarly, persistent AKI occurred in 9 of 16 patients with high risk APOL1 genotype and 17 of 88 of those without high risk APOL1 genotype; RR for persistent AKI: 2.91 (1.59–5.34), p=0.0006.

Conclusions

High-risk APOL1 genotype in AAs is associated with greater risk for AKI stage ≥ 2 and persistent AKI in COVID-19. Whether the increased AKI risk is driven by a greater risk for inapparent glomerular insult, a tubular insult or other factor is not known and deserves further investigation. This observation may have significant public health implications.

109 Sex differences in hypertension and renal injury in 2-kidney 1-clip goldglatt hypertensive rats: effect of ovariectomy

E Pemberton*

W Shao

AL Bell

L Navar

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

We previously demonstrated sex differences in hypertension in rats with unilateral renal artery stenosis (2K1C), with females developing a significantly lower degree of hypertension and renal injury vs. males. This study evaluates the possible role of estrogen as protective in renovascular hypertension by comparing blood pressure and renal function in intact and ovariectomized 2K1C female rats.

Methods Used

We studied 4 OVX and 4 control female rats. A 0.2 mm silver clip was placed on the left renal artery of OVX rats, and blood pressures (BP) of both groups were recorded on days -1, 3, 7, 14, and 21 with a tail cuff. Rats were placed in metabolic cages for 24 hours to measure water intake and urine volume. Rats were subjected to clearance studies on day 22. Following anesthesia with pentobarbitol, the jugular vein was cathetorized and infused with an albumin/inulin/PAH saline solution (1.2 mL/hour). Arterial pressure was continuously measured with a femoral artery catheter. The right and left ureters were catheterized, and urine flow was collected in 30 min periods over 2 hours for uAGT ELISA and renal function analyses. Right and left kidneys were sectioned for RNA and histology to determine degree of kidney injury.

Summary of Results

Preliminary findings show BP readings in OVX 2K1C rats trending higher than intact 2K1C females, with statistical difference by day 21. Importantly, OVX 2K1C rats did not show statistical difference in BP, urine volume, or urine flow versus males. OVX clipped kidneys showed reduced kidney function compared to intact 2K1C clipped kidneys, trending similar to male 2K1C data. Nonclipped kidneys of OVX rats showed significantly increased uAGT excretion versus CK, further supporting the role of intrarenal RAS in mediating hypertensive response in 2K1C animals.

Conclusions

Increases in urinary angiotensinogen in OVX rats indicate augmented intrarenal AngII levels which associates closely with the decreased renal function in OVX rats vs. control and vs. intact females. This suggests that removal of estrogen eliminates its protective role against hypertension. Tissue analysis of renal injury is pending; however, these preliminary findings help explain sex-differences in hypertension and facilitate research into treatment and management of hypertension in women.

110 Markers of inflammation and risk for acute kidney injury and need for dialysis in patients with covid-19

J Walker*

A Torres-Ortiz

AE Mohammed

M Mohamed

I Lukitsch

J Velez

Ochsner Health System, Jefferson, LA

Purpose of Study

Acute kidney injury (AKI) is a reported manifestation of COVID-19 (CoV-AKI). Release of inflammatory cytokines has been recognized as a characteristic feature of COVID-19 and is linked to severity of illness. However, it has not been clearly determined if levels of serum markers of inflammation are associated with risk for development of AKI or its severity.

Methods Used

We conducted an observational study in patients hospitalized at Ochsner Medical Center over 1-month period with COVID-19 and diagnosis of AKI. We examined the relationship between the blood level of ferritin, C-reactive protein (CRP), procalcitonin (proCal), D-dimer and lactate dehydrogenase (LDH) and the incidence of AKI, as well as AKI requiring renal replacement therapy (AKI-RRT), by assessing comparison of means and proportions and by logistic regression analysis.

Summary of Results

Among 644 patients with COVID-19, we compared 161 (26%) with AKI vs 414 (64%) without AKI. Median serum creatinine on admission was higher in the AKI group (1.8 vs 1.1 mg/dL, p<0.0001). Preexisting chronic kidney disease rates were comparable (35% vs 28%, for AKI and no AKI groups). The median value of inflammatory markers on admission were higher in the AKI group [ferritin 1016 (516–2534) vs 680 (315–1416) ng/mL, p<0.0001; CRP 163 (93–243) vs 93 (46–165) mg/L, p<0.0001; proCal 0.37 (0.2–1.6) vs 0.12 (0.06–0.32) ng/mL, p<0.0001; D-dimer 1.57 (0.96–5.14) vs 1.13 (0.68–2.57) mcg/mL, p=0.0004; and LDH 532 (365–804) vs 428 (309–548), p=0.0004]. On multivariate logistic regression analysis, CRP (p=0.003) and ferritin (p<0.035) were associated with greater risk for AKI. In addition, ferritin ≥ 1200 ng/mL and CRP ≥ 300 mg/L were independently associated with AKI [adjusted odds ratio: 2.3 (1.3–4), p=0.003, and 2.5 (1.0–6.3), p=0.05; respectively]. Furthermore, ferritin, CRP, proCal and LDH levels were significantly higher in those with AKI-RRT compared to those not requiring RRT (p=0.022 to p=0.009).

Conclusions

Higher level of inflammatory markers were associated with CoV-AKI, and levels were even higher for those with CoV-AKI-RRT. In patients with COVID-19, magnitude of ferritin and CRP on admission could be used for AKI risk stratification.

Joint SSCI/SAFMR plenary session

9:00 AM

Saturday, February 27, 2021

111 Abstract withdrawn
112 Abstract withdrawn
113 Abstract withdrawn
114 Which group of patients withdraw from a pulmonary rehabilitation program?

B Mantilla*

MN Vinan Vega

K Nugent

Texas Tech University, Lubbock, TX

Purpose of Study

Pulmonary rehabilitation (PR) is an evidence-based, non-pharmacological therapy for patients with COPD to improve dyspnea, exercise capacity, and health-related quality of life. Despite the clear benefits associated with PR, there is a significant drop- out rate associated with worse clinical outcomes. The following study aims to investigate the profile of patients with chronic lung disease who did not complete the PR program at the University Medical Center in Lubbock, Texas.

Methods Used

We retrospectively reviewed the medical records of patients who completed and dropped out from the PR program during 2014 to 2019. The adherent and non-adherent patients were compared based on age, gender, FEV1,% FEV1, 6-minute walk distance, and number of hospitalizations prior to the initiation of PR. Variables were analyzed using means ± standard deviations and percentages. Comparisons between groups were made using paired t-tests or chi-square tests with the GraphPad software. P-values ≤ 0.05 were considered statistically significant.

Summary of Results

Forty-eight percent of 277 patients withdrew from the pulmonary rehabilitation program. The mean number of sessions in the drop out group was 12.35 ± 14.15. More females and younger patients were in the drop out group. There were no significant differences in FEV1 and%FEV1 between the two groups. Patients who withdrew from the pulmonary rehabilitation program had a lower initial 6-minute walk distance and a higher number of hospital visits (table 1).

Abstract 114 Table 1

Profile of patients who completed (Group 1) and who dropped out (Group 2) of the pulmonary rehabilitation program

Conclusions

Predictors of non-adherence to PR include younger age, female gender, worse exercise tolerance and more hospital visits. Program coordinators need to spend extra time with these patients in an effort to determine barriers to participation and improve completion rates.

115 Sodium-glucose cotransporter 2 inhibition attenuates the intrarenal renin-angiotensin system in a rat model of polycystic ovary syndrome

J Pruett1*

S Everman1

ED Torres Fernandez2

D Romero1,3

L Yanes Cardozo1,3

1University of Mississippi Medical Center, Jackson, MS

2The University of Texas at Austin, Dell Medical School, Austin, TX

3Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age. PCOS is characterized by hyperandrogenemia and ovulatory dysfunction, and it is highly co-prevalent with several cardiovascular risk factors such as obesity, increased blood pressure (BP), and insulin resistance (IR). The renin-angiotensin system (RAS) appears to be dysregulated in PCOS as well. Current treatments for these cardiovascular risk factors in PCOS are lackluster. We tested the hypothesis that administration of a sodium-glucose cotransporter 2 inhibitor (SGLT2i) will attenuate the RAS in a PCOS rat model.

Methods Used

Four-week old Sprague Dawley female rats were randomized to either control or dihydrotestosterone (7.5 mg/90 days). At 12 weeks old (wo), rats were divided to receive drinking water or the SGLT2i empagliflozin (10 mg/kg/day) for 3 weeks (n=7–10 per group). Adiposity was analyzed by EchoMRI. Renal cortices and medullas were collected for real time PCR for intrarenal RAS components. Angiotensin-converting enzyme (ACE) activity was measured fluorometrically. BP was measured by radiotelemetry during SGLT2i treatment.

Summary of Results

PCOS rats have increased adiposity, leptin, IR, renal ACE mRNA expression, and BP. SGLT2i decreased fat mass (21.1 ± 2.7 vs 12.2 ± 0.8 g, P<0.01) and leptin (0.86 ± 0.16 vs 0.45 ± 0.05 ng/mL, P<0.05) in PCOS. SGLT2i decreased BP in PCOS. In the renal medulla of PCOS, SGLT2i decreased mRNA expression of ACE and angiotensin II type 1 receptor. Furthermore, in PCOS, SGLT2i decreased medullary ACE activity (5573.0 ± 563.4 vs 3707.1 ± 430.2 nmol/min/mg, P<0.01). However, plasma ACE and IR were unchanged by SGLT2i in PCOS.

Conclusions

SGLT2i decreases activation of the intrarenal RAS in PCOS, which was associated with decreased adiposity, leptin, and BP. This suggests that SGLT2i, through attenuation of the intrarenal RAS, could be a novel therapeutic agent for reducing BP and obesity in women with PCOS. Funded by COBRE/MS CEPR P20GM121334.

116 The suppression of collagen induced arthritis using collagen with post-translational modifications

HH Odens*

V Woo-Rasberry

A Kang

L Myers

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Purpose of Study

Rheumatoid Arthritis is an autoimmune arthritis involving degradation of cartilage, hyperplasia of the synovium, and infiltration of mononuclear cells. Collagen has been proposed as a potential suppressive agent for autoimmune arthritis because it can stimulate the Leukocyte-associated immunoglobulin-like receptor 1 (LAIR-1) which suppresses the activity of immune cells such as CD4+ Th1 cells. Post-translational modifications (PTM) are essential processes used by eukaryotic cells to diversify their protein functions and dynamically coordinate their signaling networks. Recently there has been a renaissance of interest in the possibility that citrullination (Cit) of proteins triggers more severe inflammation. The goal of this research was to use the collagen-induced arthritis animal model to test whether citrullination of Type I(I) collagen chains would alter its ability to suppress collagen induced arthritis (CIA).

Methods Used

Groups of 10 DR1 mice were injected intraperitoneally with either: (1) Type I(I) collagen chains, (2) citrullinated Type I(I) collagen chains, or (3) phosphate-buffered saline (PBS). Each mouse was given four doses of 100µg each over the span of four weeks and the severity of arthritis were determined by visual examination. Each mouse was scored thrice weekly and the mean severity score was recorded at each time point.

Summary of Results

We found that Type 1(I) significantly reduced the severity of arthritis in the DR1 mice while mice treated with cit- Type 1(I) developed more severe arthritis (severity scores of 0.5±1 vs 4.9 ± 6, p ≤ 0.04). The antibody responses to collagen were also studied to compare the outcomes following each treatment. Results demonstrated that mice treated with the non-cit Type I(I) collagen group had lower antibody levels to native type II collagen compared to the citrullinated Type I(I) collagen group and the PBS control group. These mice also had significantly lower antibody titers to cit type I collagen.

Conclusions

This data suggests that type I collagen suppresses both the severity of arthritis and the antibody titers to collagen probably by stimulating LAIR-1 and that citrullination of the collagen interferes with this process.

SSPR plenary session

9:00 AM

Saturday, February 27, 2021

117 Intranasal insulin and sex-specific effects on long-term neurobehavioral outcomes following hypoxic-ischemic brain injury in neonatal rats

N Dankhara*

JW Lee

N Ojeda

S Lu

E White

S Xu

C Glendye

Y Pang

AJ Bhatt

L Fan

University of Mississippi, Jackson, MS

Purpose of Study

Intranasal insulin (InInsulin) administered immediately following hypoxic-ischemic (HI) exposure improves early neurobehavioral outcomes and reduces ipsilateral brain damage in 10 days old (P10) neonatal rats. The current study’s objective was to test whether InInsulin provides long-term neuroprotection against neonatal HI-induced brain injury evaluated in juvenile rats at P 21-25.

Methods Used

At P10, Sprague-Dawley rat pups were randomly divided into four groups: Sham+Vehicle; Sham+Insulin; HI+Vehicle; and HI+Insulin; with an equal male/female ratio. Pups either had HI exposure by ligation of the right carotid artery followed by 90 min of hypoxia (8% O2) or sham surgery followed by room air exposure. Immediately after HI or Sham, pups received either InInsulin (25 μg) or vehicle (2.5 μl) in each naris, followed by 4 more doses every 24 hours. The Sham+Vehicle served as control. Neurobehavioral tests were performed from P21 to P25 in a double-blind manner. Brain injury evaluation by stereology technique were performed on P25. Statistical analysis was performed via two-way ANOVA followed by the Holm-Sidak method. The sample size was calculated to find a difference of 22% between means with a power of 85% and a significance of p < 0.05.

Summary of Results

Our representative results showed that InInsulin protects both male and female pups against HI induced abnormal sensorymotor disturbances measured by beam walking and vibrissa forelimb placement tests (P20), less anxiety-like behavior during the elevated plus-maze test (P21), and abnormal long-term memory evaluated by novel object recognition test (P23). Only male pups had abnormal short term memory following HI during the Y maze test (P21) and memory phase of the passive avoidance test (P25), the findings were improved in HI+Insulin pups; (p < 0.05, n = 8/sex/groups/all tests). InInsulin also protected against HI-induced reduction of hippocampal volume (p < 0.05, n = 4/sex/groups)

Conclusions

Neonatal HI induced abnormal long-term neurobehavioral outcomes are worse in male pups; nevertheless, InInsulin improves all outcomes. Our results provide strong evidence in support of InInuslin as a non-invasive therapy for HI brain injury in term neonates.

118 Endothelial adenosine monophosphate-activated protein kinase alpha (AMPKα) deficiency potentiates hyperoxia-induced experimental bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH)

A Elsaie*

R Menon

A Shrestha

B Shivanna

Baylor College of Medicine, Houston, TX

Purpose of Study

BPD-associated PH is a common life-threatening sequela of preterm infants that lacks curative therapies. We showed that hyperoxia increases lung AMPKα activation in neonatal mice. Whether this alteration is a compensatory or contributory phenomenon in hyperoxia-induced experimental BPD is unclear. Thus,we hypothesized that endothelial AMPKα-deficient neonatal mice would be more susceptible to hyperoxia-induced experimental BPD and PH than their wild-type littermates.

Methods Used

To determine the necessary role of endothelial AMPKα signaling in neonatal lung injury, we decreased endothelial AMPKα expression by breeding AMPKα-1flox/flox mice with Tie-Cre mice, and exposed endothelial AMPKα-1 sufficient or deficient mouse pups to air or hyperoxia (70% O2) from PND1-14. Lung morphometric and echocardiographic studies were done on PND28 to determine the effects of AMPKα-1 gene and hyperoxia on alveolarization, lung vascularization, pulmonary vascular remodeling, and PH. To determine the sufficient role of AMPK signaling in neonatal lung injury, C57BL6J mice were treated with daily i.p. injections of 1 mg/kg of the AMPK agonist, aminoimidazole-4-carboxamide ribonucleotide (AICAR) while they were exposed to air or hyperoxia through PND1-14. Lung morphometric studies were done on PND14 to determine the effects of hyperoxia and AMPKα activation on alveolarization and lung vascularization.

Summary of Results

Hyperoxia induced alveolar simplification, as evidenced by decreased radial alveolar counts and increased mean linear intercepts. Hyperoxia also decreased lung angiogenesis. Further, hyperoxia induced pulmonary vascular remodeling and PH, as evidenced by increased medial wall thickness of resistance lung vessels, decreased pulmonary acceleration time/ejection time ratio, and increased right ventricular systolic pressure. However, these effects of hyperoxia were augmented in the presence of endothelial AMPKα-1 deficiency. By contrast, AICAR-mediated AMPKα activation attenuated hyperoxic lung injury.

Conclusions

Our findings indicate that AMPKα signaling mitigates hyperoxia-induced experimental BPD and PH in neonatal mice. We propose that AMPKα is a potential therapeutic target for BPD infants with PH.

119 Loss of growth and differentiation factor 15 exacerbates neonatal hyperoxic lung injury

F Al-Mudares*

K Lingappan

Baylor College of Medicine, Houston, TX

Purpose of Study

Bronchopulmonary dysplasia (BPD) is one of the most common morbidities among surviving premature infants. BPD is characterized by abnormal alveolar septation and aberrant vascular development. Growth Differentiation Factor 15 (GDF15) is a divergent member of TGF-β superfamily and its expression increases under various stress conditions including inflammation, hyperoxia, and senescence. Our prior studies showed that GDF15 expression is increased in neonatal mouse BPD models and that GDF15 loss exacerbates oxidative stress and decreases viability in human pulmonary endothelial and epithelial cells. Our overall hypothesis that loss of GDF15 will exacerbate hyperoxic lung injury in the neonatal lung in vivo.

Methods Used

We exposed neonatal Gdf15-/- mice, and wild type (WT) controls on a similar background to room air or hyperoxia (95% O2) for 5 days after birth (saccular stage of lung development). The mice were euthanized on PND 21(alveolar stage of lung development). Lung morphometry was evaluated by the mean linear intercept (MLI). Pulmonary vessel density and macrophage count were quantified using immunohistochemistry. Statistical analyses were performed using the Prism 8 software.

Summary of Results

Upon exposure to hyperoxia, the survival in Gdf15-/- mice was significantly decreased compared to WT mice (26% vs 57% respectively, p <0.01) (n=32–54/group). MLI was increased by hyperoxia exposure in both genotypes. Interestingly, alveolar simplification was higher in the Gdf15-/- females than WT females when exposed to hyperoxia (MLI = 30.0µm vs 26.2µm respectively; n=3–5/group, p <0.001), with no significant difference among WT and Gdf15-/- males. Interestingly, Gdf15-/- mice had lower macrophage count in the lung compared to WT mice (macrophage counts/HPF = 4.9 vs 12.4 respectively, n=8/group, p <0.001), with no sex-specific differences. The pulmonary vascular density was decreased in hyperoxia with no significant differences between both genotypes.

Conclusions

Our results suggest that in the neonatal mouse BPD models, loss of GDF15 exacerbates neonatal hyperoxic lung injury with respect to alveolar development. We are currently measuring the cell-specific expression of GDF15 in the neonatal lung at different developmental time points. GDF15, a stress responsive cytokine, may modulate alveolarization in the developing lung.

120 Association between choice of anti-seizure medications and treatment failure in neonates with seizures

E Sewell1,2*

SE Hamrick1,2

RM Patel1,2

MM Bennett3

V Tolia3

K Ahmad4

1Emory University School of Medicine, Atlanta, GA

2Children’s Healthcare of Atlanta Egleston Hospital, Atlanta, GA

3Baylor Scott and White Health, Dallas, TX

4Baylor College of Medicine, San Antonio, TX

Purpose of Study

To compare treatment failure between: (1) infants treated with phenobarbital (PHB) versus levetiracetam (LEV), for first-line treatment and (2) infants treated with phenytoin (PHT), compared to LEV, as second-line treatment following PHB.

Methods Used

This retrospective cohort study included infants with seizures in the Pediatrix Clinical Data Warehouse from 2009–2018. We included neonates admitted for at least 3 days who received PHB or LEV as the initial anti-seizure medication (ASM) and excluded patients who received more than one ASM on the same day due to the inability to discern sequence of administration. Our primary outcome was treatment failure, defined as the need for additional ASM. Mixed effect logistic regression was used to compare the risk of ASM treatment failure after adjusting for confounding factors, including center.

Summary of Results

Of the 6,842 included infants from 255 NICUs, 6,213 were treated with PHB and 629 were treated with LEV as first-line treatment. Of those treated first-line with PHB, 835 and 325 were treated second-line with PHT and LEV, respectively. The incidence of treatment failure was 31% in infants receiving first-line PHB, compared to 38% in infants receiving LEV (adjusted OR: 0.70; 95% CI 0.58, 0.84); there was no significant difference in mortality (adjusted OR 1.17; 95% CI 0.71, 1.94). Among PHB-treated infants receiving LEV compared to PHT as second-line treatment, there was no significant difference in treatment failure (22% vs. 26%, adjusted OR 0.76; 95% CI 0.54, 1.08), however second-line PHT use was associated with a higher odds of mortality (adjusted OR 2.34; 95% CI 1.35, 4.04).

Conclusions

Initial treatment of neonatal seizures with LEV, compared to PHB, is associated with a higher rate of treatment failure. Among infants receiving PHB, second-line treatment with PHT, compared to LEV, was not associated with increased treatment failure, but was associated with increased mortality.

121 Algorithmic model for accurate and timely diagnoses of appendicitis in children

E Florez*

J Sitta

S Miller

A Smyly

E Varney

ST Lirette

CM Howard

University of Mississippi Medical Center, Flowood, MS

Purpose of Study

Ultrasound (US) is the first-line imaging modality to diagnose appendicitis in children followed by computed tomography (CT). However, appendicitis evaluation in obese children through US has limitations that lead to additional imaging evaluations, delays in treatment, and increased cost. Our goal is to develop a model to predict which imaging modality (US or CT) would provide the most accurate diagnosis based on the body habit of children with appendicitis.

Methods Used

This is a HIPPA-compliant, IRB approved single-center retrospective study. Pediatric patients with appendicitis symptoms admitted to the emergency room between 2015 and 2019 were enrolled (N=1111). Patients that underwent both US and CT were included in the study (N=396). Two independent readers performed anthropometric measurements such as waist circumference (WC) and sagittal abdominal diameter (SAD) using a DICOM viewer. Four readers contoured fat and muscle depots of a single CT slice centered at the L4-L5 intervertebral disc using a segmentation software. Statistical analyses were performed with Stata softwa. Linear Pearson coefficient was used to correlate WC and SAD with body composition and BMI. Inter-observer agreement was assessed by the intraclass correlation coefficient (ICC) with 95% CI. Finally, a model was developed to determine the probability of seeing the appendix by US.

Summary of Results

The predictor model was based on BMI interactions (AUC=0.65, p<0.001). The model showed that the appendix in patients with BMI ≥ 20 kg/m2 has <50% probability of being detected by US, which resulted in a high number of unidentified appendixes (>60%). This limitation was evidenced when ~30% of the diagnoses obtained using CT and US were discordant. Thus, our model suggests using CT images prior to diagnosing appendicitis or normal appendix. WC and SAD demonstrated a strong direct correlation with BMI (R2=0.88 and R2=0.86 respectively, p<0.001) and total adipose tissue (R2=0.80 and R2=0.79 respectively, p<0.001). Both intra- and inter-observer agreement were excellent (0.99 ICC, 95%CI).

Conclusions

Our model allows a rapid and easy determination of the best imaging modality to diagnose appendicitis based on BMI while reducing the delay in diagnosis and misdiagnosis in a diverse pediatric population.

122 Management and short-term outcomes of infants born to mothers with active perinatal covid-19 infection

J Lien*

J Desai

AJ Talati

V Lamba

UTHSC, Memphis, TN

Purpose of Study

The risk of perinatal transmission of COVID-19 to infants born with active maternal infection is not well established. Recommendations regarding isolation and discharge practices have changed through the pandemic and best practices to minimize risk of postnatal infection are evolving. Additionally, there is the concern of late presentation after hospital discharge in those born to mothers with active infection

Methods Used

In this prospective cohort, we identified mother-infant dyads with active maternal perinatal COVID-19 infection between April and October 2020. Perinatal infection was defined as positive maternal SARS-CoV-2 PCR between 14 days prior to 3 days after delivery. We established local guidelines for management of such dyads based on national recommendations and as they evolved, so did our practice. Infants got SARS-CoV-2 PCR testing on nasopharyngeal swabs at 24 and 48 hours of life. In addition, we followed infants post-discharge with phone calls at 1, 2, and 4 weeks of age.

Summary of Results

We included 43 mother-infant dyads with active maternal perinatal infection. Of 43 mothers, 27 (63%) were black, 26 (60%) were COVID-19 positive at time of delivery, 8 (19%) were symptomatic within 14 days of delivery. Of 43 infants, 23 (53%) were male and 7 (18%) were preterm. Mean GA and BW were 37.9 ± 2.8 weeks and 3.08 ± 0.65 kg, respectively. Median (IQR) lengths of maternal and infant hospitalization were 2 (1 – 3) days and 3 (2 – 5.5) days, respectively. Seven infants (16%) required respiratory support, 4 (9%) were intubated with 1 infant requiring ECMO. Only 7 (16%) infants were fed breastmilk. All infants were tested for SARS-CoV-2, 42 (98%) neonates were negative with 1 infant being positive at 48 hours of life, who remained asymptomatic. During 4 week follow-up, period 98% (39 of 40) of infants were asymptomatic, with 1 having febrile UTI.

Conclusions

The risk of perinatal transmission with appropriate isolation measures as described is extremely low. In our cohort, only a single infant tested positive which was likely due to transient colonization. No infant had symptoms directly attributable to a SARS-CoV-2 infection during the initial hospitalization and up to 4 weeks of age.

Adolescent medicine and general pediatrics

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
123 Argininosuccinate lyase deficiency (ASLD) incidence and management in Oklahoma

FM Boulos*

Y Enchautegui-Colon

D DeMarzo

S Palle

AC Tsai

The University of Oklahoma Health Sciences Center, Edmond, OK

Case Report

Argininosuccinate Lyase Deficiency (ASLD) is a rare disorder of the urea cycle. Argininosuccinate lyase is the enzyme that cleaves argininosuccinic acid (ASA) to produce arginine and fumarate in the fourth step of the urea cycle. For ASLD, while dietary restrictions of protein and supplementation with arginine are mainstays of management; the liver could still sustain damage from ASA accumulation and patients eventually become candidates for orthotopic liver transplantation (OLT).

ASLD is found at relatively higher incidence in a Burmese refugee population in northeastern Oklahoma, the Zo people whose native language is Zomi. These patients present with consanguinity borne of seclusion. We have had the unique opportunity to manage 9 patients identified after the initiation of statewide expanded newborn screen with ASLD, ages ranging from 5.5 months to 8 .5 years old with a 4:5 male: female ratio. Four patients were of Zo origin, with the unique homozygous missense pathogenic variant c.707G>A, p.Arg236Gln presenting with hyperammonemia while the other 5 patients presented with variable degree of developmental delay with or without liver disease. We are conducting a longitudinal follow up study with emphasis on some key differences in management and outcome. Our outcome measures include the amount of arginine supplementation and need for OLT.

Our data suggest that the deleterious nature of the pathogenic variants played an important role in the clinical manifestations of the disease?. – (This sentences is was hard to read, so check this out?) A recent study suggests limiting arginine dose to 100 mg/kg/day, however based on our experience this dose is not sufficient with the severe pathogenic variant identified in our cohort: c.707G>A, p.Arg236Gln. Indeed, the dose of arginine also depends on the protein intake of the patients which should be adjusted critically during the first 2 years of life, with dosages as high as 300 mg/kg/day. OLT was performed in 4/9 (44%) of these patients. These preliminary findings provide basis for continued expansion of early detection and further research into the treatment algorithms needed to optimize quality of life for those affected with this unique disorder.

124 Adverse childhood experiences correlate to depressive symptoms in adolescents

R Garrison*

K Tawse-Butha

S Myers

JJ Burns

University of Florida, Pensacola, FL

Purpose of Study

Adverse childhood experiences (ACE’s) such as child abuse, parental mental illness/substance abuse, domestic violence and parental absence confer lifelong health risks. The purpose of this study is to determine if there is a correlation between childhood ACE’s and adolescent depression.

Methods Used

The research team conducted a retrospective chart review including patients who completed the ACE’s assessment questionnaire and the PHQ-9 depression screen at their visit to an Adolescent Medicine teaching clinic. ACE’s scores were then compared to PHQ-9 scores categorically using a 2 × 2 cross-table (Chi-square). Scores on ACE’s ≥4 and PHQ-9 ≥10 were defined as high scores based on the literature.

Summary of Results

119 adolescents completed both ACE’s and PHQ-9 screening surveys at the time of their visit, with 92 (77.3%) having ACEs scores <4, and 27 (22.7%) having scores of ≥4. There were 90 (75.6%) with PHQ-9 depression scores <10, and 29 (24.4%) having scores ≥10.

On crosstab analysis, those with ACE’s scores <4, had PHQ-9 depression scores ≥10 in 18 (19.6%; (expected count 22.4) whereas for those with ACE’s scores ≥ 4, PHQ-9 scores were ≥10 in 11 (40.7%; expected count 6.6). This difference was statistically significant (Chi-square 5.1, p=0.024). Table 1.

Abstract 124 Table 1

ACE’s Score vs. PHQ-9 Score (Chi-Square 5.1, p=0.024)

Conclusions

Having high number of adverse childhood experiences correlates with depressive symptoms later in adolescents. Early interventions during childhood to prevent the mental health consequences of ACE’s should be a priority.

125 Predicting inpatient croup outcomes

WC Hancock1,2*

M Scott1

J Winer1,2

1The University of Tennessee Health Science Center, Memphis, TN

2Le Bonheur Children’s Hospital, Memphis, TN

Purpose of Study

To describe inpatient racemic epinephrine (RE) use for croup through emergency department (ED) parameters including time between RE treatments.

Methods Used

We completed a retrospective chart review of patients admitted with a diagnosis of croup age 2 months to < 7 years old from 2016 to 2019 at a mid-south children’s hospital. All patients received at least one treatment of RE prior to admission. Patients with congenital airway anomalies, prior tracheal surgery, initial PICU admission, complex medical conditions, previous admission within the past 30 days, other primary diagnoses, or missing records were excluded. We assessed patient demographics, laboratory studies, radiologic studies, and other management in the ED. Data was analyzed using logistic regression.

Summary of Results

Of 386 identified patients, 238 were included. 59 (24.7%) of these patients received additional RE during admission. The median time between 1st and 2nd doses of RE in the ED did not differ between patients who did not receive inpatient RE and those that did (1.90 hours vs. 1.85 hours, p = 0.71). Overall length of stay for patients who did not receive inpatient RE was significantly less with a median of 16.7 hours (p <0.001). Patients with age-defined tachypnea (OR 2.33, p = 0.10) and who were afebrile (OR 0.417, p = 0.016) in ED triage were more likely to require RE during admission.

Conclusions

In patients admitted with croup, duration of time between RE doses did not provide significant predictive value for whether patients would require additional RE in the inpatient setting. Absence of fever and age-related tachypnea were found to be significant predictors of inpatient RE use.

Abstract 125 Table 1

Multivariate logistic regression for patients requiring inpatient RE

126 Gastric perforation: a rare complication in anorexic patients

A Hassan*

A Landmann

S Lawlis

A Ruiz-Elizalde

AB Middleman

The University of Oklahoma Health Sciences Center, Oklahoma City, OK

Case Report

Spontaneous gastric perforation in patients with eating disorders is a rare entity associated with high mortality. We present a case of an anorexia nervosa patient who had a gastric perforation. This patient’s poor nutrition likely led to impaired immune response which simultaneously masked and protected against this life-threatening condition.

A 13-year-old girl with a history of anorexia nervosa was admitted for severe malnutrition. Her diet had been very poor prior to presentation, mean estimated body mass index (MEBMI) was 61.5%. She denied binge eating, vomiting, diet pill, or diuretic use. She had cachexia, breast atrophy and cool extremities. She was started on a low intake (~1400 calories/day) refeeding plan. On day 1, she had mild abdominal pain that responded well to Tylenol. She had difficulty finishing her meals on day 2 and was given naso-gastric feeds to supplement. Her belly was soft and bowel sounds were present through the afternoon of day 2. At breakfast on day 3, the patient collapsed; she had a distended abdomen, absent bowel sounds, blue lips and a blood pressure of 65/35. Abdominal imaging revealed free air under the diaphragm. Emergent laparotomy was done with aspiration of ~4 liters of undigested food, including the salad she had at lunch on her first day. The stomach was perforated with partial necrosis. Dusky appearance of diaphragm, peritoneum and colon indicated abdominal compartment syndrome. The patient had a sub-total gastrectomy with J tube placement and, over time, was slowly transitioned to oral feeds with good weight gain.

Gastric perforation in anorexic patients is due to smooth muscle atrophy, diminished cytokinin release and autonomic dysfuntion. The contents of aspiration indicate that she had a perforation well before the clinical signs manifested. Immune abnormalities due to severe malnutrition likely caused this delayed response. Although rare, providers managing refeeding among severely malnourished patients should be aware of the risk of perforation as well as the possibility that such a critical condition may be masked by immune system derangement.

127 Louisiana pediatricians’ beliefs and practices regarding adolescent parents

N Khorsandi*

S Dumas

LSUHSC-New Orleans, Metairie, LA

Purpose of Study

Parenting adolescents face unique medical and psychosocial obstacles. Therefore, pediatricians are recommended to provide a medical home for both adolescent parents and their children. Pediatricians can provide guidance regarding contraception, continued education, social resources, and domestic violence and mental health screening. It is unknown how many pediatricians continue to provide such vital primary care for adolescent parents.

Methods Used

An anonymous, 20-question survey was sent via email to 886 Louisiana pediatricians who were either members of the national or state chapter of the American Academy of Pediatrics. The survey included questions on pediatricians’ demographic characteristics, sexual health counseling practices, and beliefs and experiences with adolescent parents.

Summary of Results

Of 101 respondents (11% response rate) the majority were white, female, and ages 30–49. Of all respondents, 79% indicated they provide primary care to adolescent mothers; nearly all agreed that adolescent mothers are at higher risk of social problems (99%) and mental health issues (92%); and 73% felt equally as comfortable treating adolescent females as younger children. Only 20% felt less qualified than other physicians to provide care for adolescent mothers. While 54% felt that adolescent mothers should continue receiving care from pediatricians, 70% felt that adolescent fathers should.

Conclusions

Louisiana pediatricians recognize the social and mental health disparities faced by adolescent mothers and the majority continue providing their primary care. However, many more pediatricians believe they should care for adolescent fathers than believe they should care for adolescent mothers. Although further analyses of this data is ongoing, these initial findings generate hypotheses that merit further examination, such as what beliefs or biases may influence pediatricians’ attitudes about adolescent mothers, and whether further pediatrician training and support in the area of reproductive health can improve their confidence in providing the pediatric-focused primary care that adolescent mothers need.

128 Remaining flexible: a case of meningoencephalitis

M Lai*

H Elaasar

S Sarkar

Louisiana State University, New Orleans, LA

Case Report

In the US, due to the availability of MMR vaccination, the incidence of mumps is 1 per 100,000. With increased rates of vaccine exceptions, we may begin to see a reemergence of historic diseases. In areas without access to this vaccine, mumps is the cause of up to 20% of meningitis and meningoencephalitis cases. Here we present an unusual case of meningoencephalitis potentially related to this phenomenon.

A 14-year-old unvaccinated male was admitted to hospital for a 7-day history of headache, fever, photophobia, and neck pain. Lumbar puncture showed opening pressure 51 mmHg, 88 WBC, 39 glucose, and 158 protein. MRI revealed diffuse supratentorial and infratentorial leptomeningeal enhancement with corresponding T2 FLAIR hyperintensity, compatible with meningitis. The patient developed altered mental status, hypotension, and papilledema. Acyclovir was started, and he was transferred to the PICU, where he was intubated for respiratory failure. Meningitis/Encephalitis PCR panel, bacterial cultures, and autoimmune encephalopathy panel were negative. Given unvaccinated history, mumps IgM/IgG were obtained and found to be 1.03/<0.2.

In the PICU, he developed an AKI requiring CRRT. After extubation, he reported profound weakness. MRI brain was repeated and showed increased T2 signal intensity along the bilateral corticospinal tracts extending from the posterior limb of the internal capsule to the bilateral cerebral peduncles and the ventral medulla oblongata, consistent with meningoencephalitis. MRI spine showed ill-defined increased T2 signal involving the length of the central spinal cord with increased leptomeningeal enhancement along the conus medullaris, concerning for diffuse myelopathy or longitudinal extensive transverse myelitis. The patient received IVIG and five courses of plasmapheresis with symptom improvement. Repeat testing revealed elevated mumps IgG, but due to IVIG therapy, diagnosis could not be confirmed without future repeating testing.

While this patient initially presented with classic aseptic meningitis, his clinical course evolved rapidly and unexpectedly, requiring constant reassessment to guide workup. This case demonstrates the importance of keeping a broad differential, maintaining clinical flexibility, and tailoring workup for special populations, such as unvaccinated patients.

129 Vitamin K and ECMO for neonatal hypoxic respiratory failure

N Lock*

A Sawyer

L Wise

J Bhatia

B Stansfield

Augusta University, Augusta, GA

Purpose of Study

The need to maintain a relative coagulopathy during ECMO runs leads to complications from thrombotic or hemorrhagic events. Decreased vitamin K concentration or activity may underscore many of the bleeding complications observed in critically ill neonates. The study centered around evaluating the complications and outcomes in neonatal ECMO patients who received intravenous vitamin K during circuit runs to determine if vitamin K was safe and would improve the complication rates during ECMO use.

Methods Used

A retrospective single center review compared complications (both thrombotic and hemorrhagic) and blood product use for neonates who received (n=21) or did not receive (n=18) a single dose of intravenous vitamin K after initiation of ECMO for respiratory failure. Following implementation of routine vitamin K for prothrombin time (PT) ≥14s during ECMO, outcomes were described in 89 consecutive neonates supported with ECMO for respiratory failure from 2014 to 2019. A subgroup of babies with congenital diaphragmatic hernia on ECMO was also described to compare.

Summary of Results

Neonates who received vitamin K experienced fewer thrombotic complications and similar hemorrhagic complications as neonates who did not receive vitamin K. Total blood product exposure was modestly increased in neonates who received vitamin K, which was attributed to a higher exposure to fresh frozen plasma. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the descriptive cohort, survival off ECMO for the cohort was 94.4%. Thrombotic complications occurred in 35.9% of the cohort and 100% of CDH neonates while bleeding complications occurred in 15.7% of the cohort and 13.3% of CDH neonates who received vitamin K for PT ≥14s during ECMO.

Conclusions

Intravenous vitamin K is safe for use during ECMO and may be beneficial in neonatal ECMO to help reduce complication rates.

130 Breastfeeding versus formula feeding in an urban academic general pediatrics clinic

MK McEwen*

J Yaun

L Correa

J Gutman

LBonheur Children’s Hospital, Memphis, TN

Purpose of Study

Exclusive breastfeeding through 6 months of life is recommended by the AAP. Benefits for the infant include a decrease in infections and obesity, and benefits to the mother include a decrease in postpartum bleeding and cancer. Despite these benefits, many mothers in our clinic choose not to breastfeed. According to the TN Department of Health, 75.8% of TN infants born in 2017 had ever breastfed, compared to the national average of 84.1%. The rates appear to be even lower in our patient population. Our study seeks to determine the rate of breastfeeding in our clinic and the motivation behind the choice to breastfeed or formula feed. This information can be used to guide resident counseling to mothers in hopes of increasing our clinic breastfeeding rate.

Methods Used

IRB approval was obtained. A 16-question multiple-choice survey was given to mothers of newborn infants at their newborn well child checks. The surveys, without identifying factors, were collected by residents. The data was entered into a database for analysis.

Summary of Results

25 surveys were collected, and 22 were fully completed. Based on preliminary data, 36% of mothers are formula-feeding exclusively, 28% are breastfeeding exclusively, and 36% are doing both. The majority of first-time mothers are planning on breastfeeding. Almost 50% of mothers who choose to breastfeed state their motivation is believing it’s ‘best for the infant.’ The infant-feeding practices of friends did not influence mothers; however, their own mothers’ practices had influence. 17% of women noted work was the reason they are formula-feeding and 17% noted free formula received through WIC led them to formula-feed; 21% of women choose formula because they had used it prior. 80% of women stated they have received breastfeeding education. Finally, most women receive WIC benefits.

Conclusions

Our results indicate that most women are formula-feeding or supplementing with formula. Most women who choose to formula-feed do so out of convenience or because they receive WIC benefits. Some women had not received education about breastfeeding or its benefits. These results confirm lower breastfeeding rates in our clinic and support a need for reevaluation of our understanding of mothers’ choices for infant-feeding. The information gathered can be used to guide counseling for our community.

131 Rare case of severe COVID-19 in otherwise healthy infant at 4 days of life

J Morris*

A Gubbels

C Meyer

NP Shah

University of Alabama at Birmingham, Birmingham, AL

Background

COVID-19 is considered to be relatively rare in the neonatal period. Transmission primarily occurs via respiratory droplets from a caregiver in the postnatal period. Two groups of neonates are currently believed to be higher risk of severe disease– preterm infants and those with underlying medical conditions.

Methods Used

We present case report of a neonate with severe COVID-19 presenting at our institution.

Case presentation

4-day-old female, born at 39 weeks via normal spontaneous vaginal delivery with no birth complications, experiences a brief resolved unexplained event (BRUE) during outpatient COVID swab. Family reported infant had not been feeding well and at that time five household members were known COVID-positive. She was admitted to the Pediatric Intensive Care Unit (PICU) after desaturation to 87% while feeding. She was confirmed to be COVID positive.

She had persistent apneic and bradycardic spells that prompted intubation until day 3 of stay. Following extubtation, she repeatedly desaturated to the mid-80s while on high flow nasal cannula, requiring reintubation on day 5. During this time, sepsis workup was done which was negative; additional negative studies included head ultrasound, pre/post-ductal saturation, viral respiratory panel, HSV PCR, and metabolic panel. On day 12, she again desaturated and was found to have a right pneumothorax on chest x-ray necessitating chest tube placement. On day 17, she was given convalescent plasma and dexamethasone for lung support due to persistent viremia. She was extubated on day 25 and transferred to a floor bed on day 26.

She had to be retransferred to the PICU twice during hospitalization for persistent respiratory distress with recurrent right pneumothorax. In addition to broad-spectrum antibiotics, she also received remdesivir on compassionate-use basis. She was discharged at day 68 of stay with 41 days of admission to PICU.

Conclusions

Contrary to popular belief, severe neonatal COVID-19 infection is not limited to infants born prematurely and those with preexisting medical conditions. It is critical to counsel families on the risk of exposing newborns to known COVID-positive individuals.

132 Persistent eosinophilia and fever in pancreatitis: a clinical conundrum

JP Noel*

N Sharma

A Fields

R Arrouk

Augusta University, Augusta, GA

Case Report

A healthy 11-year-old girl presents with epigastric abdominal pain, fever, weight loss, and decreased appetite for one month. On physical exam, she appears ill, dehydrated, and cachectic. Her abdominal exam is significant for large ascites with a fluid wave and is non-tender to palpation. Her labs show leukocytosis with an eosinophilic predominant granulocytosis and an absolute eosinophil count of 6,800/mm3. She has elevated serum inflammatory markers, hypoalbuminemia, and lipase is 5,000 U/L. Her renal and liver function panels were normal. MRCP shows an irregular and dilated pancreatic duct throughout the pancreatic body and tail with no evidence of pancreatic divisum or choledocholithiasis. She was diagnosed with pancreatitis with pancreatic duct obstruction and subsequently underwent ERCP with pancreatic stent placement, paracentesis, and colonoscopy. Her peritoneal fluid was significant for an eosinophilic predominant granulocytosis with no evidence of malignancy on flow cytometry. All cultures and gram stains were negative. Her gastrointestinal biopsies showed no specific abnormalities on pathology review with no evidence of eosinophilia involving her gastrointestinal mucosa.

Following stent placement, her lipase initially decreased. However, on postoperative day 18, she developed a fever with night sweats. On exam, she was febrile, tachycardic with abdominal distention. Empiric, broad-spectrum antibiotics were initiated due to concern for infected pancreatic necrosis versus spontaneous bacterial peritonitis. Repeat MRCP showed interval development of two peripancreatic fluid collections and re-accumulation of ascites. She continued to have daily fever ranging from 39–40°C. Repeat paracentesis and evaluation of her peritoneal fluid showed resolution of eosinophilia with an elevated neutrophil count, negative gram stain, and no growth on culture. She completed a 10-day course of antibiotics, however, remained febrile with elevated inflammatory markers and leukocytosis throughout her hospitalization. A genetic panel to evaluate for a hereditary cause of chronic pancreatitis was sent and returned positive for a mutation of the serine protease inhibitor Kazal type 1 (SPINK1).

133 Pediatric clonidine poisoning a quarter-century later

JC Pruett1*

NP Shah1

K Gutermuth1

B Whitworth2

A Slattery2

K Monroe1

MH Nichols1

1University of Alabama in Birmingham School of Medicine, Hoover, AL

2Alabama Poison Information Center, Birmingham, AL

Purpose of Study

Clonidine, originally designed as an antihypertensive agent, has also been used in the treatment of various behavior and sleep disorders. Over time, prescription of clonidine to children for these conditions have increased. In our prior study on clonidine, the epidemiology, management, and a review of clonidine related hospitalizations in children were studied from 1987–1992. The purpose of this study is to describe the changes in these parameters for clonidine exposures at the same institution, a quarter-century later.

Methods Used

We conducted a retrospective study of clonidine ingestion in children ages 0–6 from 2013–2018. Our poison center’s database was queried and a list of cases was obtained. Only cases where clonidine was the sole ingestant were included. Using electronic medical records we obtained demographic information and patient management data including use of and response to naloxone. Descriptive analysis was performed to calculate frequencies and proportions. We compare findings from this study with the prior study.

Summary of Results

80 cases were included in the current study, there were also 80 cases in the prior study. The median age of all patients was 2.4 years (IQR: 1.8 to 3.1). Clonidine prescribed most often belonged to the patient’s sibling (30.0%), the patient’s grandparent (26.3%), or self (12.5%); compared to the previous study of 1987–1992 where clonidine most commonly belonged to the grandmother (54%). 88.8% of patients in this study utilized Medicaid as their primary insurance, compared to 34% with Medicaid coverage as their primary insurance in the prior study. 88.8% of patients were admitted to an intensive-care unit for monitoring, with an average length of stay of 21.6 hours. 11.5% of patients required intubation due to respiratory failure. Naloxone was utilized in 53.8% of patients, with 60.5% noting symptom improvement, compared to 49% of patients receiving Naloxone with 16% showing improved symptomatology in the prior study.

Conclusions

As clonidine is being prescribed more frequently to pediatric patients, toxic exposures in children are more likely to come from a sibling or a medication prescribed to self than a grandparent. Naloxone as an antidote for clonidine can prove to be effective.

134 Teenager with history of vaping diagnosed with E-cigarette or vaping product use-associated lung injury (EVALI)

R Ramakrishnan*

C Murray

MR Roca Garcia

University of South Alabama, Mobile, AL

Introduction

Recent data has shown that usage of electronic cigarettes (e-cigarettes) is steadily increasing among high school students in the U.S. Reports have shown e-cigarettes to cause a broad spectrum of pulmonary disease including lipoid pneumonia, acute eosinophilic pneumonia, hypersensitivity pneumonitis and diffuse alveolar hemorrhage. More recently this entity called E-Cigarette or vaping product use-associated lung injury (EVALI) has been more widely seen.

Case Description

13-year-old female admitted due to respiratory distress with concern of atypical pneumonia evident on chest X-ray. She was otherwise healthy with no underlying disorders. Initial laboratories showed leukocytosis at 23,000 and a CRP of 4.7. Patient disclosed daily use of multiple vaping products including BidiTM Stick, TKO TM, Bang TM, Vuse TM, and NJOY TM. The patient was managed with albuterol, ceftriaxone, azithromycin as well as systemic steroids and did not require supplemental oxygen while admitted. Patient was provided cessation education and a cessation hotline number on discharge along with antibiotics and steroids to complete dosing course.

Discussion

E-cigarettes function by conversion of liquid to vapor by adding heat, thus the term ‘vaping’ is commonly used. Symptoms of EVALI include dyspnea, chest pain, cough, hemoptysis and gastrointestinal symptoms like nausea, vomiting, abdominal pain with fever and malaise. Patients often present with tachycardia, tachypnea, fever and hypoxemia, like our case. Computed Tomography is the preferred imaging modality to diagnose EVALI and the mainstay treatment is administration of steroids. A positive response to steroids suggests an inflammatory pathway in the progression of EVALI, as evident in our patient.

Conclusions

Increasing use of e-cigarettes and vaping products are linked with significant lung injury in adolescent population. In teenagers presenting with respiratory distress, the likelihood of EVALI should be considered. Investigation into personal history of vaping is the cornerstone of diagnosis and can be challenging. It is imperative to highlight case reports and implement education with community support to aid in cessation of use.

135 Nurse practitioner-performed point-of-care ultrasound to assess bladder fullness prior to formal transabdominal pelvic ultrasound in a pediatric emergency department: a randomized controlled trial

S Ruffenach1*

KR Richard2

NP Shah1

M Baker1

M Thompson1

1The University of Alabama at Birmingham, Birmingham, AL

2Duke University, Durham, NC

Purpose of Study

At many institutions, the standard of care is to place a urinary catheter which is then used to instill saline into the bladder to ensure fullness prior to formal pelvic ultrasound (US) in Pediatric Emergency Departments (ED). This study aims to evaluate whether a certified registered nurse practitioner (CRNP)-performed bladder US to ensure bladder fullness prior to formal US can reduce the time in minutes needed to complete pelvic imaging compared to the invasive urinary catheter method. Additionally, it aims to compare patient-reported pain with these two methods.

Methods Used

This study utilizes a randomized controlled trial with 2-group parallel design with female patients aged 8–18 years in the Children’s of Alabama Pediatric ED requiring pelvic US. After informed consent, patients were randomized to one of two groups: the standard group received a urinary bladder catheter followed by formal pelvic US and the experimental group underwent periodic CRNP-performed point-of-care bladder US in addition to self-reported sensation of bladder fullness. When the bladder was found to be full patient was sent for formal pelvic US. Once imaging completed patients were asked to report the pain associated with receiving a catheter versus point-of-care ultrasound. Data collected included demographics, time when pelvic US ordered, time when pelvic US completed, pain score on a scale of 0–10. Primary outcomes were the time in minutes from when the pelvic US was ordered to when the images were available and patient-reported pain score. The secondary outcome was the success rate of obtaining pelvic US images on first attempt. As per power analysis, the total sample size required for the study is 48 with 24 in each group.

Summary of Results

Enrollment is underway, results pending completion of enrollment. To date, 30 patients have been enrolled.

Conclusions

Enrollment is underway, conclusions pending completion of enrollment.

136 Acute flaccid paralysis, a lesson in timing

A Sarma1*

M Huttner2

K Moussavi2

I Temple3

1Tulane University, New Orleans, LA

2University of Queensland, Ochsner Clinical School, New Orleans, LA

3Ochsner Medical Center – New Orleans, Ochsner Medical Center – New Orleans, New Orleans, LA, US, Hospital, New Orleans, LA

Case Report

Huttner, Madelyn; Moussavi, Kiana; Sarma, Arunava; Temple, Israel

Introduction

Acute flaccid paralysis is term which groups a number of uncommon but potentially devastating childhood nervous system diseases, including but not limited to acute flaccid myelitis, transverse myelitis, Guillain Barre, and disseminated encephalomyelitis. There is wide variation in the etiology of these diseases but the treatment and diagnostic studies are similar.

Background

We describe the case of a previously healthy 3-year-old female with no significant medical history who presented with a 2-day history of refusal to walk, urinary retention, and increasing lethargy. MRI at time of admission showed cord expansion from the cervicomedullary junction to T12 as well as diffuse leptomeningeal enhancement. An acute flaccid paralysis workup was initiated. She was started on IVIG and solumedrol for treatment of the inflammation. Plasmapheresis was considered but declined due to risks and decreased likelihood of efficacy due time from initial symptoms. She was also provided Fluoxetine due to some evidence showing in vitro response in CNS enterovirus infections. Infectious disease labs were only notable for HHV IgG + as well as HSV+, rheum labs were only notable for mildly elevated SSA. Encephalitis workup was negative. AFM panel was negative. The patient had minimal response to steroids and IVIG, with continued need for bladder caths and limited ability to move bilateral legs. She was transferred from our facility to neuro-rehab continued care.

Discussion

Acute flaccid paralysis is a broad term for a number of neurological disease processes characterized by weakness or paralysis and reduced muscle tone. Both the diagnostic evaluation and treatment are time-sensitive and should be initiated as soon as possible after the patient develops symptoms. Diagnostic evaluation includes MRI, CSF studies, autoimmune studies, and stool, serum, nasopharyngeal swabs for viral etiologies. Treatments are usually aimed at reducing the inflammatory state and include IVIG, steroids, plasmapheresis but studies are limited and it is difficult to make conclusions about efficacy.

137 Kidney allograft outcomes in pediatric patients transitioning to adult care-a single center pilot study

S Subramanyam*

KM Wille

M Seifert

V Kumar

G Towns

G Agarwal

S Ong

The University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

The transition of healthcare for young people with kidney transplants from pediatric to adult care settings is an area of need, hitherto under-recognized in adult care centers. The outcomes of pediatric patients transitioned to adult care has not been studied rigorously at our transplant center and may help identify areas for intervention.

Methods Used

We performed a pilot study to retrospectively review the outcomes of the recent 29 kidney transplant patients who transitioned care from Children’s of Alabama to University of Alabama at Birmingham between 1/1/2017 and 9/30/2020. Statistical analyses were performed using JMP (Cary, NC).

Summary of Results

61.1% of our patients were male, 45% were African American and 40% were White. Median age at transplant and at transition were 16.2 years (IQR 13.9–17, range 9–18.4) and 19.9 years (IQR 19.6–20.7, range 18.5–21.9) respectively and median age at last follow up was 21 years (IQR 20–22). Median time from transplant to transition was 4.3 years (IQR 2.5–5.0). Median creatinine at transition was 1.3 (IQR 1.1–1.9). At the time of transition, ten patients (34%) had a history of organ rejection, 6 (21%) had a history of a positive donor-specific antibody (DSA). Within 2 years following transition, 6 (20%) developed de novo DSA, 4 patients (14%) developed acute rejection and 4 (14%) developed graft failure (3 had acute and 1 had chronic rejection). Nearly all patients received maintenance immunosuppressive regimen consisting of tacrolimus (93%), mycophenolate mofetil (86%) and prednisone (93%). All 4 graft losses occurred within 1 year of transition and of the 4, 3 had a pre-transition history of acute rejection and/or DSA. On bias-reduced logistic regression analysis models that included de-novo DSA, acute rejection after transition and creatinine at transition were not associated with graft loss within 2 years of transition.

Conclusions

A significant number of patients transitioning to adult care already have a history of organ rejection and DSA. In a 2 year period following transition, graft loss rate was low. None of the factors studied were associated with graft loss likely due to the low event rate. Additional data collection is underway to verify this finding and to identify areas for future intervention.

Adult case reports/Aging/Geriatrics

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
138 A rare cause of acute acalculous cholecystitis

A Alexander1*

F Ibrahim2

1The University of Alabama at Birmingham, Huntsville, AL

2UAB-Huntsville, Huntsville, AL

Case Report

A 40 yo male presented to the emergency department with 2 days of abdominal pain, nausea, vomiting, and poor oral intake following 2 weeks of diarrhea. The pain was burning, worse with meals, and rated as a 10/10 at its worst. He denied fever, chills, hematochezia, melena, chest pain, or shortness of breath. He had no past medical history, recent travel or sick contacts, and was taking no prescribed or over the counter medications. Exam was significant for RUQ tenderness without guarding, rigidity, organomegaly, or masses. Laboratory results were significant for total bilirubin 2.8 mg/dL, direct bilirubin 2.5 mg/dL, alkaline phosphatase 358 EU/L, ALT 1771 EU/L, AST 1535 EU/L. Abdominal ultrasound found no abnormality of the liver, but a contracted gallbladder, with wall thickening measuring 3.4 mm. CT scan of the abdomen confirmed mucosal hyperemia and pericholecystic edema, no gallstones were visualized. Hepatitis panel was reactive for hepatitis A IgM, indicating acute viral infection. The patient was managed symptomatically, without improvement. On day 4, total bilirubin increased to 4.8 mg/dL. HIDA scan confirmed biliary obstruction with cholecystitis. Laparoscopic cholecystectomy was performed without complication, finding an acutely edematous, distended, acalculous gallbladder. Abdominal pain, nausea, and vomiting resolved, diarrhea improved. Patient was discharged home with self-care.

This patient had acalculous cholecystitis superimposed on acute hepatitis A. Hepatitis A remains asymptomatic or presents with self-limiting abdominal pain, nausea, vomiting, diarrhea, or jaundice. Hepatitis A Virus has rarely been associated with the invasion of the biliary ducts and gallbladder epithelium. The subsequent cell mediated immune response can lead to acute acalculous cholecystitis. Persistent, severe abdominal pain in the setting of increased bilirubin indicates further evaluation for biliary obstruction, as treatment with laparoscopic cholecystectomy may lead to symptomatic improvement and prevent life threatening complications of gangrene, perforation, and empyema. It is important to consider acalculous cholecystitis as a potential etiology of RUQ pain in the setting of hepatitis A with hyperbilirubinemia, with surgical excision as the curative treatment.

139 Mollaret’s meningitis

E Alshaikh*

A Baggett

Univeristy of Alabama at Birmingham – Huntsville Hospital, Huntsville, AL

Case Report

A 31-year-old female presented with progressive headache, nausea and neck stiffness for 2 days. She reported a history of aseptic meningitis and herpes zoster infection. She had photophobia, neck stiffness and positive meningeal signs.

She had unremarkable complete blood count, comprehensive metabolic panel, brain computerized tomography and brain magnetic resonance imaging. Lumbar puncture showed colorless CSF, with 333 cells/mm3 (62% lymphocyte), 88 mg/dl protein and 58 mg/dl glucose. Meningitis panel was positive for HSV2.

Initially, she received Vancomycin, Cefrtiaxone and Gancyclovir which were discontinued after the negative blood and CSF cultures. The patient improved with Acyclovir and discharged on Valacyclovir.

Discussion

Mollaret’s meningitis (recurrent benign aseptic meningitis) is a rare condition, characterized by multiple episodes of fever and meningeal irritation. It is most commonly caused by Herpes Simplex Virus type 2 (HSV-2). It can be associated with HSV-2 genital ulcers and Varicella Zoster virus.

Lifelong HSV prophylaxis has been proposed for Mollaret’s meningitis in some case reports however data to support prophylaxis use remains limited. At least one case report showed a possible reduction in the frequency of recurrence with the continuous suppressive Acyclovir therapy. On the other hand, one randomized control study concluded that Valacyclovir cannot be recommended for prevention.

One of the characteristic features of Mallaret’s meningitis is the spontaneous resolution of symptoms in few days to weeks. Despite that several medications have been used in many reported cases including antiviral therapy like Acyclovir and Valacyclovir. There are no studies to prove the benefits of antiviral treatment nor clear treatment guidelines which could be attributed to the small number of reported cases.

We report this case to improve the awareness, reduce the use of unnecessary medications and provide more data for future investigations regarding treatment and prevention.

140 ‘TOE’ing the line: COVID19 and acro-ischemia

L Al-Sukhni*

I Ivyanskiy

T Naguib

Texas Tech University HSC Amarillo, Amarillo, TX

Case Report

The coronavirus (COVID-19) has infected more than 6.5 million people in the United States. Worldwide, confirmed deaths are nearing the 1 million mark.

Severe COVID-19 infection is characterized by an upregulated innate immune response, a hypercoagulable state, and a range of pulmonary, gastrointestinal, and dermatological manifestations. Various polymorphous cutaneous lesions have been described in the evolving literature, including livedoid eruptions, morbilliform rashes, and acral lesions. The underlying pathophysiology could include vasodilation, hypercoagulability, or increased vascular permeability.

Here, we present two cases of severe COVID-19 infection that involved a prolonged stay in the ICU and intubation. The hospital course was complicated by an acute kidney injury, requiring renal replacement therapy, and septic shock. Early during the hospitalization, both cases developed acro-ischemia, also referred to as pseudo-chilblains, of the distal lower extremities. Both patient survived and subsequenlty discharged to rehabilitation facility.

141 An unusal cause of pleural effusion

R Bankusli*

RK Bankusli

University of Mississippi Medical Center, Jackson, MS

Introduction

Urinothorax is a rare thoracic complication involving the presence of urine in the pleural cavity through a retroperitoneal leakage frequently caused by obstructive uropathy or mechanical genitourinary (GU) injury. Diagnosis of urinothroax requires a high clinical suspicion specially in patients with recent abdominal surgical intervention.

Case Description

A 21 year old man with recent hospitalization for left kidney stone presented with fever, shortness of breath and new large left sided pleural effusion. During his recent hospitalization, he underwent percutaneous nephrostomy tube placement, and lithotripsy that was complicated by MRSE bacteremia. He was discharged with appropriate antibiotics. On admission, thoracentesis of the left pleural cavity showed exudative fluid with inflammatory cells and pleural to serum Cr ratio of 1. A repeat CXR the following day showed re-accumulation of fluid in the left pleural cavity requiring a second thoracentesis yeilded similar fluid analysis. A technetium 99m renal scan demonstrated increased radiotracer uptake in the left hemithorax suggestive of urinothroax; however, it was unable to delineate a definitive sinus tract between urinary systems and chest cavity. Given the recurrence of fluid in the left hemithorax, chest tube was placed with intra-pleural alteplase and dornase to expedite the drainage of exudative effusion. The rate of fluid accumulation decreased over time, and the chest tube was removed. He was discharged on antibiotics.

Conclusion

Urinothroax is a clinical diagnosis and should be included in the differential diagnosis of pleural effusion in any patient with a recent history of urological, gynecological, or intra-abdominal procedure. Pleural fluid analysis seen in our patient showing both infectious and urinoma was intriguing and required further investigation with radiotracer renal scan. Although pathological tract was not discovered, the evidence of radiotracer in the left hemithorax cemented our differential diagnosis. Urinothorax may self-resolve with supportive measures such as serial thoracentesis or chest tube placement with the resolution of obstructive uropathy.

142 More than a headache: anaplastic pleomorphic xanthoastrocytoma

AM Bonano-Rios*

K Andino Lebron

W Caceres-Perkins

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Chronic headache is a common complaint in the outpatient setting with multiple etiologies, including malignancy. Anaplastic Pleomorphic Xanthoastrocytoma (APXA) is a rare brain tumor composing less than 1% of all astrocytoma and 62 adults diagnosed per year. APXA presents as a slow-growing mass in the temporal lobe, with new onset of seizures. We present the case of a successful treated patient of APXA which presented with indolent headaches.

A 41-year-old man with a two-month history of progressive headaches, described as pressure-sensation 10/10 located at bitemporal area. These headaches were associated with photophobia and phonophobia and interfered with his activities. Rest of review of system was negative. Physical examination negative for neurological deficits. CT scan revealed a mass on right frontal lobe. MRI with IV gadolinium showed an intra-axial mass measuring 2.7 cm with vasogenic edema and mass effect upon right lateral ventricle, displacement of frontal horn and a midline shifting. Staging CT Scans negative for metastasis. Vasogenic edema was treated with Dexamethasone and the patient had resection of tumor.

Pathology report had leptomeningeal and subarachnoid invasion. Tumor cells with nuclear pleomorphism, multilobed and multinucleated forms, nuclei with herniated eosinophilic cytoplasmic profiles, and up to 7 mitoses 10 high-power fields. Immunohistochemistry (IHC) was + S100, +GFAP and +vimentin and negative for the mutation in V600 of BRAF gene. The patient was diagnosed with APXA WHO Grade III. The patient had full recovery and is on active surveillance with serial Brain MRIs without recurrence.

APXA has an overall survival rate of 40–50% within five years. This case demonstrates the importance of adequate history and physical examination for headache stratification and workup. Also, the importance of IHC and cytogenetic testing for prognosis and identification of target therapy. Medicine is dynamic and multidisciplinary, but its foundation starts with an assertive history and physical examination for adequate management of a time-sensitive diagnosis.

143 A heart too sweet: a case report of myocardial infarction triggering diabetic ketoacidosis

CM Cepero-Jimenez*

V Vando-Rivera

GJ Torres-Rivera

Z Mirza

J Casal-Hidalgo

CA Cortes

VA Caribbean Healthcare System, Aibonito, Puerto Rico

Case Report

Diabetes ketoacidosis (DKA) is a life-threatening complication more commonly seen with type 1 than type 2 diabetes mellitus (T2DM), with an increasing hospitalization rate of more than 140,00 per year. DKA can be precipitated by severe stressors like infections, medication noncompliance, drugs, or new-onset diabetes. Non-infectious etiologies for DKA responsible for 4% of the cases include myocardial infarction, cerebrovascular accidents, pancreatitis, among others. We present a case of acute myocardial infarction (MI) triggering diabetic ketoacidosis in a patient with T2DM.

A 73-year-old male with hypertension, T2DM and chronic kidney disease, presented with nausea, vomiting, and diarrhea. Patient was found critically ill and hemodynamically unstable, requiring intravenous fluids and vasopressors. Laboratories showed leukocytosis, hyperglycemia over 1500 mg/dL, high anion gap metabolic acidosis, lactatemia, elevated b-hydroxybutyrate, acute kidney injury and severe hyperkalemia. Elevated highly sensitive troponins of 439 ng/L, which peaked at 6915 ng/L. EKG showed peaked T waves and wide QRS complex managed with intravenous calcium gluconate, insulin and emergent hemodialysis was started. Subsequent EKG showed atrial fibrillation with fast ventricular response and inferolateral ST segment depressions. No infectious foci were found, nor culprit drugs on further review. Cardiac catheterization showed 90% stenosis of the mid left anterior descending coronary artery and branch, and the patient underwent bypass graft surgery upon resolution of his DKA. Findings were consistent with a type 1 non–ST segment elevation myocardial infarct as the cause of his DKA.

MI accounts for approximately 1% of the precipitating causes of DKA in T2DM and responsible for 28% of the deaths in these patients. Painless acute coronary syndrome should always be considered in the setting of DKA without apparent precipitant, especially in elderly patients with multiple risk factors for coronary events as they have been associated with high mortality risk. Early detection of DKA precipitants allows prompt guided therapy, metabolic recovery, and improved prognosis.

144 Fourth time’s the charm: the importance of clinical judgement in COVID-19

CM Cepero-Jimenez*

E Partida-Rodriguez

V Vando-Rivera

AM Bonano-Rios

J Gutierrez-Nuñez

VA Caribbean Healthcare System, Aibonito, Puerto Rico

Case Report

SARS-CoV-2 is an enveloped positive-stranded RNA that is part of the same family as MERS and SARS. This virus is responsible for the current COVID-19 pandemic. Symptoms varies from asymptomatic carriers to a viral-like illness with fever, shortness of breath, and cough. The preferred initial testing is a nucleic acid amplification test with reverse-transcription polymerase chain reaction assay (RT-PCR) from a nasopharyngeal (NP) swab. We present a case of positive SARS-CoV-2 infection in a patient with multiple false-negative results.

A 69 years-old male presented with fever, chills, malaise, anorexia, nausea, watery diarrhea and dry cough for 5 days. He denied sick contacts or recent travel. Vital signs were remarkable for fever and borderline blood pressures. The physical exam was unremarkable. Chest x-ray showed bibasilar airspace disease. Chest CT scan showed focal left lower lobe consolidation. He was started on empiric antibiotic therapy for community-acquired pneumonia. Laboratories were remarkable for elevated LDH, CRP, and d-dimers. Initial NP RT-PCR for SARS-CoV-2 was negative. The test was repeated on three different occasions, given the high clinical suspicion of COVID-19 pneumonia, all were negative. The patient continued with high fevers and saturation levels of less than 90%. Chest CT scan was repeated which revealed worsening with development of multifocal bilateral peripheral ground glass and air space opacities. Laboratories showed ferritin on increasing trend and CRP decreasing. Bronchoscopy was done and RT-PCR SARS-CoV-2 from bronchoalveolar lavage was positive. The patient was discharged under isolation measures. Repeated testing was negative, and he made a full recovery.

Comparative data on the accuracy of testing is limited. Preliminary data suggest that sensitivity varies between sampling specimens. Possible mechanisms include viral RNA sample degradation and poor sampling. Recent data favors testing within eight days after exposure and three days after onset of symptoms. Care must be taken in interpreting tests during the early infection period. If high clinical suspicion, infection should not be ruled out only based on NP RT-PCR SARS-CoV-2.

145 Overflow diarrhea and aki due to fecal impaction

D Dave*

I Ivyanskiy

T Naguib

Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX

Case Report

Fecal impaction is a known complication of chronic constipation and particularly bothers the elderly. Common complications include hemorrhoids, megacolon, overflow diarrhea and obstructive uropathy among others. Overflow diarrhea is often misdiagnosed and treated with antidiarrheals leading to worsening impaction. Obstructive uropathy is a well-established complication of fecal impaction with obstruction occurring at any level. The elderly are at high risk due to multiple factors including diabetes mellitus, dementia, opioid use, depression among others. Many case reports have been published with fecal impaction and obstructive uropathy though none reported overflow diarrhea as a presentation.

An 82-year-old male patient presented with diarrhea and acute kidney injury that was caused by fecal impaction that led to obstructive uropathy. He had a 4-week history of non-bloody watery diarrhea with associated fecal incontinence and generalized abdominal pain and a long-standing history of constipation prior to this. Generalized abdominal tenderness with mild diffuse distention and a distended urinary bladder were noted on exam, along with normal rectal tone and loose brown stool in absence of hemorrhoids or prostate enlargement. Lab work showed elevated creatinine and hypokalemia. Upon IV fluid resuscitation and foley catheter placement, CT abdomen was done which showed bilateral hydronephrosis. Stool studies showed no evidence of infection. He was managed with laxatives and had significant improvement in kidney function as well as reduced stool burden.

Our patient had multiple risk factors for impaction including age, immobility, diabetes, and medications including azacitidine.

Chronic constipation in our patient led to fecal impaction which eventually led to overflow diarrhea and obstructive uropathy. It is important to consider impaction as a cause of fecal incontinence and diarrhea in the elderly as it can lead to high morbidity and mortality. The treatment of this diarrhea is counterintuitive since the impaction benefits from catharsis not antidiarrheals. Diet counseling, biofeedback, and rarely surgical intervention can be used in refractory cases.

146 Not so superficial after all

CS Diaz Loza1*

S Garcia2

A Febles2

1VA Caribbean Healthcare System, San Juan

2Universidad de Puerto Rico, San Juan, Puerto Rico

Case Report

Melanoma is the most aggressive type of skin cancer and the sixth most common cancer in North America. Acral lentiginous melanoma accounts solely for 5% of all melanomas. However, it is considered the most common type of melanoma among Asians.

A 69-year-old Asian male with type 2 diabetes mellitus, psoriasis, and arterial hypertension presented with one-week history of altered mental status with associated memory loss, poor appetite, weight loss, weakness and imbalance. Initial vitals and laboratories were unremarkable. Brain CT scan revealed multiple brain lesions, but chest and abdominopelvic CT were negative. The patient had a questionable history of uncooked pork consumption. Steroids were given without improvement. Repeated head CT without contrast yielded innumerable hyper-attenuating lesions throughout the parenchyma with evolving hematoma and worsening edema, suggestive of hemorrhagic metastatic deposits. A thorough examination was solely remarkable for poor dentition with caries, psoriatic plaques throughout knees and elbows, as well as a callous-like ulceration with scant black spots in the left heel. MRI revealed an increase in the number and size of supratrentorial and infratrentorial lesions with edema, mass effect and mild left to right midline shift without herniation. Given a significant increase in the number of lesions in three days, an infectious etiology was highly suspected. Empiric antibiotic therapy was provided despite negative infectious workup. Transthoracic echocardiography revealed vegetations in pulmonic and mitral valves and a speckled pattern in the myocardium. Blood cultures remained negative. A transesophageal echocardiogram could not be performed. Biopsy of an evolving left heel callous-like ulceration with purplish hue and darker tone yielded a diagnosis of acral lentigious melanoma. New imaging revealed metastatic lesions in the abdomen, pelvis, and chest.

Acral lentiginous melanoma usually presents in the soles of the feet. This patient’s presentation is consistent with a diagnosis of metastatic melanoma with possible cardiac involvement. This case illustrates the importance of a thorough physical examination and history. By raising awareness of such an uncommon, aggressive diagnosis, we aim to ensure prompt diagnosis and better outcomes.

147 Ramsay hunt syndrome and the importance of early diagnosis

S Ginjupalli*

A Bhuiyan

Augusta University, Augusta, GA

Case Report

58 yo female w PMH of multiple sclerosis (MS) and varicella in childhood presents for eval of L cheek swelling and L ear pain. She was discharged the prior week after inpatient treatment of L otitis externa (OE) secondary to MSSA w outpatient course of Keflex and Cipro ear drops. Vitals stable and physical exam normal besides mild swelling of L cheek. Labs unremarkable. IV cefepime and vanc started w concern for malignant OE.

The next morning, L facial paralysis observed. Stroke immediately ruled out w CT. ID consulted and patient started on high-dose prednisone and acyclovir for suspicion of Ramsay Hunt Syndrome (RHS). MRI demonstrated an incidental finding of a 5 mm vestibular schwannoma (VS) near the L CN VII. DDx: RHS, Bell’s Palsy 2/2 L CN VII impingement by VS, MS flare, malignant OE. Prednisone treated both possible diagnoses of RHS and MS flare. Symptoms showed varying degrees of improvement w the start of treatment.

Critical information: ED note from initial encounter for OE details a vesicular rash on L side of the face. This was lost when presented 2/2 OE confirmed w positive pus culture of MSSA. Rash resolved prior to this hospitalization and diagnosis of RHS was missed for over one week from its initial presentation.

RHS is the reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion of CN VII. It commonly presents as a vesicular rash of the external ear/tongue/palate and acute facial paralysis. Other symptoms of RHS experienced by this patient: medial deviation of L eye (L CN VI nerve palsy), horizontal nystagmus, and hearing loss. Symptoms of RHS like nausea, vertigo, and gait abnormalities could not be discerned from her baseline 2/2 her MS.

Gold standard for diagnosis of VZV is PCR, but this test was unavailable acutely. As such, emphasis was placed on patient treatment over her diagnosis. D/t her advanced age, PMH of varicella as a child, the stress of MS, and her recent otitis externa, this patient had a higher risk for VZV reactivation. Combined w her rash from her prior ED visit and her improvement w treatment, RHS could reasonably be diagnosed.

At six-month f/u, patient continued to experience facial paralysis w difficulty closing her L eye. D/t the poor prognosis of facial paralysis 2/2 RHS, prompt diagnosis and treatment are key to prevention and good outcomes.

148 Myxoid mix-up

A Heng1*

R Mailapur2

1University of Alabama at Birmingham School of Medicine, Huntsville, AL

2Huntsville Hospital, Huntsville, AL

Case Report

A 58yo female w/a hx of HTN, hypothyroidism, depression, and fibromyalgia presented w/gradual onset of pain and swelling in her L buttock for 3 months. She described associated pain as sharp and debilitating. The pain radiated down her L leg and was aggravated by movement w/o relieving factors. She denied recent trauma, discharge, redness, numbness, or weight loss. Prior to presentation, she started taking Lyrica and had been unable to work for 5–6 wks due to generalized pain. Physical exam demonstrated a palpable 4 cm subcutaneous mass in her L buttock. The mass was non-tender, partly mobile, and firm in consistency. U/S showed a 2.3 × 1.3 × 2.5 cm hypoechoic mass. MRI w/contrast revealed a 2.7 × 2.2 × 2.0 cm mass involving the inferior L gluteus medius/maximus chest inferior to the ischial tuberosity w/iso- to hypointense signal on T1 imaging, hyperintense signal on T2 imaging, and peripheral rim enhancement. She underwent radical wide local excision of the intramuscular mass, which yielded a 6.0 × 4.5 × 3.7 cm specimen of yellow-white, fibrofatty tissue covered by small amounts of red, striated muscle. Due to concern for a soft tissue sarcoma, the specimen was serially sectioned and revealed a well-circumscribed mass measuring 2.7 × 2.5 × 1.8 cm. The mass had a white, whorled gelatinous appearance. Findings were c/w an intramuscular myxoma.

Intramuscular myxoma (IM) is a rare, benign neoplasm of mesenchymal origin w/an incidence of 1:1,000,000. Majority of lesions present in the 4th to 6th decade of life w/slight female predilection. The tumor most frequently involves large muscle groups of proximal extremities. IMs usually appear as a slow-growing solitary, painless mass that is firm and partly mobile. Sx may arise if the tumor compresses nearby structures. Multiple IMs can be observed in association w/fibrous dysplasia, in which Mazabraud’s syndrome and McCune-Albright syndrome should be considered. Nonspecific clinical sx and radiologic findings make pre-op dx challenging to distinguish IMs from other myxoid lesions, especially low-grade malignant myxofibrosarcomas. MRI is the preferred imaging modality, which characteristically shows hypointense signal on T1 imaging, hyperintense signal on T2 imaging, and peripheral enhancement. Established dx requires histopathological examination. Surgical excision is curative, and recurrence is unlikely.

149 Bullous pemphigoid mimicking cellulitis

I Ivyanskiy*

D Dave

A Dweik

J Yeary

H Yousuf

T Naguib

Texas Tech University HSC Amarillo, Amarillo, TX

Case Report

Bullous Pemphigoid (BP) is the most prevalent autoimmune blistering skin disease in the Western world affecting mainly the elderly population. The diagnosis is based on clinical assessment along with specific immunopathologic findings on skin biopsy. Risk factors include genetic factors, environmental exposures, and several infections including hepatitis B, hepatitis C, Helicobacter Pylori, Toxoplasma Gondi and Cytomegalovirus. A variety of drugs have been associated with bullous pemphigoid including but not limited to dipeptidyl peptidase-4 (DPP-4) inhibitors, loop diuretics, spironolactone and neuroleptics. Associated neurologic disorders (dementia, Parkinson’s disease, bipolar disorder, previous stroke history and multiple sclerosis) have also been described. Common clinical presentation consists of extremely pruritic inflammatory plaques that resemble eczematous dermatitis or urticaria, followed by formation of tense bullae with subsequent erosions. Typical distribution involves the trunk and extremities. Mucosa is typically spared affecting only 10–30% of patients. Several unusual clinical presentations of bullous pemphigoid have been described such as nonbullous forms with erythematous excoriated papules, plaques, and nodules. Other reported findings include urticarial lesions, prurigo-like nodules, multiple small vesicles resembling dermatitis herpetiformis or pompholyx, vegetating and purulent lesions localized in intertriginous areas, and even exfoliative erythroderma. Recognition and management of such cases can present a diagnostic challenge to clinicians. Here we describe another variant which to our knowledge is the first case to present with a cellulitis-like presentation in a patient with a known history of bullous pemphigoid.

150 COVID-19 associated with catatonia and abnormal CSF: a case report

F Jaber*

U Aisueni

T Torrico

C D’Assumpcao

T Kiong

K Sabetian

R Kuran

Kern Medical Center, Bakersfield, CA

Background

Understanding the full impact of the Coronavirus disease 2019 (COVID-19) pandemic remains a challenge for healthcare providers. Although respiratory symptoms remain the cardinal presentation, there are increasing numbers of reports documenting neuromuscular and psychiatric complications in COVID-19. To our knowledge, only two cases of COVID-19 infection associated with catatonia have been previously reported.

Case presentation

A 36-year-old African American diabetic female who has no past psychiatric history presented with vomiting, slurred speech and ataxia. Due to gastrointestinal symptoms, she was tested for COVID-19 by nasopharyngeal PCR which came back positive. MRI of the brain showed no acute intra-cranial abnormalities. Lumbar puncture showed mild CSF pleocytosis with lymphocytic predominance, increased protein and normal glucose. Common causes of aseptic meningitis/encephalitis were ruled out. As hospital course continued the patient developed ataxia and experienced behavioral changes. Starting with increased agitation and selective mutism, she eventually developed full catatonic, retarded type symptoms. The patient received IV methyl prednisone out of concern for autoimmune or paraneoplastic encephalitis with no clinical improvement. Catatonic symptoms quickly resolved with intravenous lorazepam. Neuromuscular and psychiatric symptoms had also resolved before discharge. The patient was discharged home with complaint of poor memory of her hospital course.

Conclusion

COVID-19 can present with neuropsychiatric symptoms, including catatonic symptoms, associated with inflammatory CSF changes.

151 ‘Vision loss’ in a patient with lynch syndrome

SG Jones*

R Martindale

JO Mason

University of Alabama at Birmingham Callahan Eye Hospital, Birmingham, AL

Case Report

A 47-year-old CM with PMH of Lynch Syndrome with partial colectomy presented to the ocular ED with a 1-week history of painless vision loss. The vision loss was sudden-onset, slowly progressive, and distributed like a curtain drawn down over his superior visual field. He also noted new-onset floaters and a visible ‘dust trail.’ Left eye fundoscopy revealed bullous inferior retinal detachment with an inferior mass obscuring the periphery. The mass notably had scant peripheral pigmentation with heme over the superior edge. B-scan showed low-lying serous retinal detachment in the left eye and a 12 × 16 × 14 mm echodense ciliary body tumor.

He was referred for left eye enucleation and cytology with differential of retinal detachment secondary to metastatic adenocarcinoma vs primary amelanotic melanoma of the ciliary body. Colonoscopy and endoscopy were WNL 3 months prior. Cytology was consistent with amelanotic melanoma. He was referred for metastasis workup including LFTs, CT chest and abdomen, and MRI brain.

Discussion

Retinal detachment (RD) classically presents with painless peripheral vision loss, new-onset flashes or floaters, or a curtain drawn down over the peripheral visual field. Unlike rhematogenous RD which involves a retinal tear that leads to detachment, exudative RDs occur in the absence of retinal breaks and may arise secondary to choroidal neoplasms (e.g., ciliary body melanoma). Lynch syndrome is a cancer syndrome commonly involving GI and gynecological malignancies such as adenocarcinomas. Though rare, adenocarcinomas can metastasize to the ciliary body of the eye. In this case the eye was enucleated based on COMS guidelines, which recommend observation for small tumors (<2.5 mm apical height), brachytherapy for medium-sized (2.5–10 mm height and <16 mm diameter), and enucleation for large (>10 mm height or >16 mm diameter). Primary ciliary melanoma warrants screening with LFTs and abdominal & chest imaging.

Conclusion

RD may be the presenting manifestation of ocular tumors, especially in the context of hereditary cancer syndromes. RD and suspected ocular tumor workup includes dilated eye exam and B-scan imaging. Tumor size in conjunction with differential may dictate surgical intervention prior to cytology.

152 An unusual case of non-cardiogenic pulmonary edema and hepatitis due to rickettsial infection

L Kantamneni1*

I Ingle2

1University of Alabama Huntsville Regional Medical Center, Huntsville, AL

2Park Avenue Lasek, New York, NY

Case Report

A 42 yr old African American male presented with myalgia, abdominal pain and diarrhea, he was admitted to ICU due hypotension of 90/63 mmHg. On examination his abdomen was tender with a rapid shallow breathing at the rate of 35/min. Labs were significant for WBC 14.99k, AST 119, ALT 98, Bili 4.9 mg/dl and lactate of 2.3 mmol/L. He was started on Metronidazole, Cefepime for a possible abdominal source of infection and IV vancomycin was added. Extensive workup failed to localize the source of infection. Bedside ultrasound showed diffuse B lines in all fields and no consolidation concerning for pulmonary edema. Echo revealed a EF of 20% without LVH or dilated cardiomyopathy. Right heart catheterization showed normal RA and capillary wedge pressures with reduced CO suggestive of non-cardiogenic pulmonary edema. Despite treatment he progressed with worsening WBC, transaminitis and bilirubin which prompted a liver biopsy which was normal and no congestion was noted. RMSF titres were found to be significantly elevated at IgG 1:256 and IgM 1:64. He was started on doxycycline, and he gradually improved with a down trending WBC, liver enzymes and was extubated.

RMSF is a tick-borne disease which presents with non-specific flu-like symptoms which can complicate the diagnosis but can have fatal outcomes unless treated appropriately. Our patient has all factors known to cause high case fatality associated with RMSF including African American race, alcohol abuse, G6PD deficiency, and male gender. The unlikely presentation in our patient was a challenging diagnosis until positive titres returned for RMSF. Rash usually presents late, and is difficult to appreciate due to the patient‘s skin color. The tick carries bacteria and transmits them into the bloodstream, which rapidly multiply within endothelial cells and disseminate through the blood to various areas of the body causing the multi-system disease which can rapidly prove to be fatal if not identified and treated appropriately.

153 Is concomitant steroid use and morbid obesity a risk for propofol infusion syndrome?

L Kantamneni1*

I Ingle2

1UAB Huntsville Regional Medical Center, Huntsville, AL

2Park Avenue Lasek, New York, NY

Case Report

58 year old morbidly obese African American female with history of end stage renal disease admitted for acute hypoxic respiratory failure due to COVID-19 pneumonia was intubated and placed on ventilator support. Fentanyl for analgesia and Propofol for sedation were the agents of choice. Propofol was initiated at a rate of 58 mcg/kg/min and maintained between 58–60 mcg/kg/min. On day three of admission she was found to have lipid emulsified blood in the CRRT circuit and labs revealed triglycerides 670 mg/dl, CPK 2074 U/L, potassium of 5.3 mmol/L. A diagnosis of propofol infusion syndrome was made and propofol was switched to midazolam. Over the next two days her CPK, triglycerides improved and returned to normal. Patient has multiple risk factors for the suspected propofol infusion syndrome including the dose and duration of infusion, age, obesity, concomitant steroid and vasopressor use.

Although propofol is commonly used in the Intensive Care Units, propofol infusion syndrome is a rare and potentially fatal complication. It is associated with high dose propofol infusion (>83 mcgkgmin) for a duration of more than 48 hrs. Usual presentation includes metabolic acidosis, elevated triglycerides, rhabdomyolysis, hepatomegaly, bradycardia, AKI, hyperkalemia. It is possibly secondary to impaired tissue metabolism due to inhibition of mitochondrial respiratory chain or fatty acid metabolism. Early diagnosis with a high index of suspicion, avoiding a high rate of infusion and terminating the infusion once diagnosis is established is vital. Hemofiltration is recommended when renal clearance is impaired due to the concomitant AKI which can eliminate metabolites to hasten recovery.

Abstract 153 Table 1

Labs

154 Medullary and papillary thyroid collision tumor

H Kreit*

J Guzman

F Dihowm

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Purpose of Study

Papillary thyroid cancer (PTC) and medullary thyroid cancer (MTC) have differing pathologies, histological findings, and clinical presentations. The simultaneous occurrence of both in the same thyroid accounts for less than 1% of all thyroid cancers. The purpose of this case report is to add more data to the English literature about this phenomenon, as there have only been a few cases of this occurrence.

Methods Used

Not applicable.

Case Report

A 64-year-old male with a history of COPD was recently diagnosed with PTC presented with acute hypoxemic respiratory failure, dysphagia, weight loss, and hoarseness. Patient was hemodynamically stable on admission requiring supplemental oxygen saturating 98% via nasal cannula. Physical exam was remarkable for non-tender bilateral cervical lymphadenopathy and a palpable, non-tender mass in the right anterior neck; CT neck showed a tumor in the right thyroid extending into the superior mediastinum and eroding into the trachea with cervical metastatic lymph nodes. Labs: TSH 1.19, Ca 8.8, PTH 32.1, CEA 1270, calcitonin 4070. Molecular testing: RET. Initial right neck biopsy exhibited PTC. Immunohistochemistry: positive for PAX8, Ck7, CK AE1/3, TTF1 and negative for thyroglobulin.

Left neck lymph node biopsy exhibited MTC. Immunostains: positive for CK7, calcitonin, CD56, chromogranin, synaptophysin, and negative for thyroglobulin. Mass Resection and debulking was not feasible. The patient was transferred to an outside facility for tracheal stent placement. He was to undergo radiotherapy and based on molecular testing results, the patient will be started on systemic treatment with selpercatinib.

Conclusion

The random collision theory provides an answer for the simultaneous occurrence of MTC and PTC. Theory states that two separate, distinct tumors get initiated near one another resulting in a polyclonal neoplasm. Coexistence of these cancers can be seen as mixed tumors or collision tumors. Collision tumors are two histologically distinct tumors that developed in the same site. Due to these rare findings, the clinical outcomes are poorly studied, presenting a diagnostic and treatment challenge.

155 Interesting presentation of pituitary macroadenoma

MB Lewis*

P Patel

S Duckworth

University of Mississippi Medical Center, Jackson, MS

Case Report

Pituitary tumors present with a diverse symptomatology depending on whether they secrete hormones or cause mass effect. However, 12–37% of pituitary tumors are non-functional and present asymptomatically or with minor complaints, making this a particularly challenging diagnosis. Herein, we describe a case of a hormonally inactive pituitary tumor with anatomical compression.

A 70 year old Punjabi male with type 2 diabetes and hypertension presented with altered mental status and fatigue. He had progressive memory decline and reduced mobility for three weeks. He was recently hospitalized and treated for community acquired pneumonia. At our hospital, he had dyspnea and nausea. Physical exam was remarkable for tachypnea. He was euvolemic, and the remaining exam was benign. Labs were notable for serum sodium 126 mmol/L, urine sodium 77 mmol/L, serum osmolarity 267 mOsm/kg, and urine osmolarity 448 mOsm/kg. Though we suspected syndrome of inappropriate antidiuretic hormone secretion (SIADH), patient’s sodium did not improve after fluid restriction. Further workup revealed cortisol 0.33 mcg/dL, ACTH 5.9 pg/mL, TSH 1.26 mcIU/mL, and free T4 0.447 ng/dL. He was started on stress dose hydrocortisone and levothyroxine for central adrenal insufficiency/central hypothyroidism. Low LH, FSH, and testosterone indicated central hypogonadism. MRI showed a 1.9 cm pituitary mass with superior displacement of the optic chiasm. Ophthalmology evaluation revealed only bilateral cataracts. Neurosurgery performed a transsphenoidal pituitary resection without complications. The patient had symptomatic and clinical improvement post-surgery.

Pituitary tumors present in various ways, and our case demonstrates that a thorough evaluation of nonspecific symptoms may reveal an unexpected diagnosis. SIADH is a diagnosis of exclusion, so it is important to explore other etiologies such as thyroid dysfunction, adrenal insufficiency, or primary polydipsia. Additionally, early identification of pituitary tumors can improve outcome due to their slow-growing nature. Therefore, this is a diagnosis that should not be missed. This case will change our practice in terms of considering uncommon diagnoses like our patient’s nonfunctioning pituitary tumor.

156 The impact of stressor choice on measuring physical resilience: the aric study

MR McMullan1*

B Windham1

M Griswold1

J Henegan1

C Blackshear1

A Kucharska-Newton3

P Palta2

J Schrack4

K Bandeen-Roche4

T Mosley1

1University of Mississippi Medical Center, Jackson, MS

2Columbia University Medical Center, New York, NY

3Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC

4Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Purpose of Study

Physical resilience (PR), defined generally as the ability to maintain or recover function following a stressful event, may present differentially depending on the pairings of stressors and functional measures employed. We examined effects of 3 different stressors on gait speed (GS) resiliency.

Methods Used

Among Visit 5 participants in the Atherosclerosis Risk in Communities Study (2011–13: mean age 76.35.3 years, 42% male, 24% black), 2,231 (38%) had good gait (GS>1 m/s). Resiliency was defined as maintaining good gait at Visit 6 (V6, 2016–2018) following one of three stressors occurring between V5 and V6: (1) adjudicated heart failure (HF), (2) self-reported hospitalization, or (3) self-reported low social support (lowSS; lack of help with decisions or tasks). Non-resilience included post-V5 death, (N=162, 7% of those with good V5 gait). Age-adjusted generalized linear models estimated relative rates (RR) of V6 GS>1 m/s, comparing those who experienced a stressor to those who did not.

Summary of Results

Of 74 participants with good V5 gait and a HF stressor, 22% maintained good V6 gait (i.e. 22% were GS-HF resilient). Comparatively, 57% of the 1,485 without a HF stressor retained good V6 gait; thus, good gait maintenance was 62% less likely among those with a HF stressor compared to those without, RR=0.38 (95%CI: 0.24, 0.59). GS-hospitalization resiliency was 46% (300 of 646 with any hospitalization had V6 GS>1 m/s) versus 62% (564/913 without hospitalization), RR=0.75 (0.68,0.83) and GS-lowSS resiliency was 61% (83/136), similar to the 60% (655/1,093) of those not reporting a lowSS stressor, RR=1.02 (0.88,1.17).

Conclusions

Pairing different stressors with a particular physical function measure can substantially impact resiliency classifications. Physical resilience studies should heavily consider which specific function-stressor pairings may be optimal. Comparisons of those without intermediary stressors can shed light on the importance of a function-stressor resilience pairing.

157 A rather large hiccup

R Mestres*

C Diaz

CA Cortes

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Lateral Medullary Syndrome (LMS) also known as Wallenberg syndrome refers to occlusion of the posterior inferior cerebellar arteryor vertebral artery. A characteristic presentation of this condition is loss of pain and temperature sensation on the ipsilateral side of the face and contralateral side of the body. However, it also presents as intractable hiccups, vertigo, Horner syndrome, nystagmus, dysarthria, dysphagia, and ipsilateral ataxia. The mechanism for hiccups in LMS is not well understood and there has been a documented incidence of 56% secondary to lateral medullary infarction.

This is the case of an 80 year old male patient with past medical history of diabetes mellitus type II and hypertension who was brought to the emergency department due to imbalance, difficulty with right upper extremity movement, dizziness, nausea, and hoarseness since about 2 hours prior to arrival. Associated symptoms included hiccups that preceded development of other symptoms and persisted on initial evaluation. The patient was previously independent in all activities of daily living. Physical exam on arrival was remarkable for hoarseness/dysphonia, asymmetric palate elevation, right upper extremity motor strength 4/5, and right dysdiadochokinesia. Vitals were unremarkable. Head CT without contrast was done on arrival and failed to show any acute changes. However, it displayed calcification of the bilateral intracranial vertebral arteries as well as proximal basilar artery. Therefore, suspected etiology of acute stroke was atherosclerotic disease. Given absence of contraindications for tissue plasminogen activator (TPA) and presentation within window period, TPA was administered. Subsequently, head CTA was done and results showed occlusion of the right intracranial vertebral artery and possible occlusion of the proximal right PICA, compatible with the patient’s history of acute right medullary syndrome.

The diagnosis of lateral medullary syndrome is often encountered and missed by non- neurologists. Therefore, this case serves to bring awareness to the importance and prevalence of this diagnosis and the fact that hiccups should not be undervalued. Persistent hiccups are often encountered and overlooked in the presentation of LMS; however, this could lead to further complications such as aspiration pneumonia, esophagitis, and even respiratory depression.

158 Taking care of monkey business: a case of baboon syndrome

D Ramos Ramirez*

C Cortes Sanchez

D Rivera

A Ortiz Vicil

VA Caribbean Healthcare System, Aguada

Case Report

Symmetrical drug related intertriginous and flexural exanthema (SDRIFE), also known as Baboon Syndrome given its resemblance to the red buttock of a female Baboon, is an uncommon type of drug-induced eruption. The reaction debuts within hours to days of exposure to the offending drug. Drug-induced cutaneous reactions affect around 2 to 3 percent of hospitalized patients and may represent a significant cause of outpatient morbidity.

An 87-year-old man presented to the emergency department with a diffuse maculopapular rash days after completing therapy for pneumonia. He was admitted to internal medicine ward where dermatology service evaluated the rash and identified it as a Drug eruption secondary to recent Ceftriaxone therapy. They recommended avoiding Ceftriaxone and using topical steroids for itch as needed. During his admission, he developed sepsis secondary to a multidrug resistant Pseudomonas aeruginosa bacteremia sensitive solely to Meropenem. He was started on antibtiotics but on his 10th day of therapy, a new rash, visibly different from the first, was observed over inguinal folds and flexural surface. Immunology service was consulted and confirmed the development of SDRIFE secondary to Meropenem. A biopsy was remarkable for dermal eosinophil, lymphocyte and plasma cell infiltrate supporting the diagnosis. Throughout treatment no severe reactions were observed and bacteremia therapy was safely completed. The drug was subsequently discontinued, and supportive therapy provided.

Given his multidrug resistant bacteremia was solely susceptible to the offending agent, Meropenem, the decision to cautiously continue therapy while treating his hypersensitivity reaction resulted in a positive outcome and response. In this particular case, SDRIFE proved not to be a complete contraindication to continuing therapy when concomitant topical corticosteroids were provided. Adverse cutaneous drug reactions may be commonly observed, around 1 in 1000 hospitalized patients suffer serious cutaneous drug reactions. When approaching a drug-induced cutaneous reaction, risks vs benefits of discontinuing or changing therapy must be considered to achieve the best possible outcome in each individual case.

159 A peculiar case of a gunshot wound to the abdomen

SS Raza1*

K Tyler2,1

RJ Najjar2,1

1The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

2Huntsville Hospital, Huntsville, AL

Case Report

Discussion

The prevalence of penetrating trauma is only seen in 3/100,000 live births. In these rare cases, the mainstay management of pregnant patients with trauma is to stabilize the mother to increase fetus viability. The primary assessment of hypovolemic shock required 2 large-bore IVs to administer a total of 6 units of PRBCs, 2 L of crystalloid, and 3 units of FFP. Pt’s airway was secured, breathing noted as symmetric, and no disability appreciated. These measures were instrumental to stabilize the patient for surgery and limit organ hypoperfusion. Furthermore, immediate ultrasound of the fetus and HR monitoring is required; hence, the OB/Gyn team was consulted to assess fetal viability.

In terms of management of trauma in pregnancy, bleeding needs to be localized and limited. With a uterine injury, it was beneficial to deliver the fetus, ligate the uterine arteries, and apply continuous uterine massage. REBOA was utilized to provide adequate circulation to vital organs. Zone 1 placement allowed initial stabilization and blood flow to the heart and brain. Shifting the REBOA to Zone 3 allowed for preserved circulation to the kidneys and liver. Focused approaches to restrict bleeding and provide adequate circulation eventually stabilized the patient and were imperative in recovery.

160 Vocal cord paralysis associated with multiple sclerosis

M Samman1*

C Tang2

1New York Center for Voice and Swallowing Disorders, New York, NY

2Kaiser Permanente Medical Center, San Francisco, CA

Case Report

A 57 year old male with a history of MS initially presented to the Head and Neck Surgery clinic with laryngeal candida. One month after presentation, patient developed new left vocal cord paralysis.

Results

Computed Tomography scan of the neck did not reveal any masses or abnormalities along the path of the recurrent laryngeal nerve. Patient’s voice improved after vocal cord injection augmentation and voice therapy.

Conclusion

Although MS was first described in 1964 to be a cause of vocal cord paralysis, a vocal cord deficit is rare, as there have been less than 10 articles regarding this subject matter. We describe a case of vocal cord paralysis associated with a central nervous system demyelinating disease and review the literature on such etiology.

161 The unidentified offender

TN Sanders1*

KS Ivey2

1Edward Via College of Osteopathic Medicine – Auburn Campus, Auburn, AL

2UAB-Huntsville, Gadsden, AL

Case Report

63-year-old man with history of myelofibrosis, s/p allogeneic stem cell transplant in 2018, off immunosuppression for 3 months, who presented with 5 weeks of intermittent fevers up to 102.7, malaise, productive cough, and dyspnea, with hypoxia on admission, requiring up to 5L O2. Labs showed WBC 10.8, 53% PMNs, CRP 12.9 mg/dL, ESR >80, ferritin 2563, and Na 130. CTA chest showed patchy groundglass opacities and tree-in-bud nodularity; repeat CT five days later due to ongoing fevers despite cefepime and doxycycline showed worsened diffuse GGO in the bilateral upper lobes and RML. Echo revealed newly reduced EF 35–40% with global hypokinesis. Cardiac MRI showed myocardial edema and transmural enhancement, suggestive of myocarditis.

Infectious workup was unrevealing, including blood and sputum cultures, respiratory viral panel, CMV and EBV DNA PCR, fungal serologies, Q-fever, Bartonella, tickborne serologies, HIV, T-spot, and Legionella. He had two negative COVID-19 tests (unknown type) prior to admission, and two negative NP PCR tests and a negative SARS-CoV-2 antibody test in-house. Late in his course, transbronchial biopsy showed mild nonspecific inflammation with negative stains and cultures. He defervesced, and was discharged on room air after 11 days.

His acute hypoxemic respiratory failure was presumed to be due to viral pneumonia and myocarditis. In an allogeneic SCT recipient with respiratory symptoms, various infectious and noninfectious etiologies (GVHD, autoimmune, drug toxicity, etc.) should be considered. Bronchoscopy can provide a more definitive etiology, and was delayed in this case due to some concern for COVID-19 despite multiple negative tests.

Abstract 161 Figure 1

Axial view. Diffuse ground-glass opacity; can be seen with COVID-19 pneumonia, but nonspecific.

162 Hereditary hypophosphatasia in a 30 year old female with chronic bone pain

KR Stanek*

M Shank

University of Colorado, Highlands Ranch, CO

Case Report

Hereditary hypophosphatasia (HPP) is a rare autosomal recessive disorder, characterized by disrupted mineralization of bones and teeth. It is often caused by loss-of-function mutations in the ALPL gene that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase. Symptoms include defective mineralization of bones and teeth, premature loss of teeth, and decreased serum alkaline phosphatase activity. Sever cases may also include fractures, rickets, and respiratory insufficiency. Chronic bone pain is a common symptom, but less specific, and often preceded by gross deformities. Adult onset HPP can be missed, given the uncommon and complex nature of the disease. There have been few reports of HPP presenting in adulthood, which were often mistaken for osteoporosis.

In the current case, the patient was a 29 year old female with a long history of chronic, progressive bone pain who presented to her family medicine physician. As a child and adolescent, her bone pain was classified as growing pain. Her alkaline phosphatase level at the time of the visit was 31 U/L (Reference: 35–147 U/L). She previously had decreased alkaline phosphatase levels intermixed with levels on the low side of the normal range. The bone pain was extremely distressing for the patient and she voiced her concerns to her family medicine physician. He noted decreased alkaline phosphatase levels and discussed possible genetic causes. Genetic testing identified an ALPL gene .571G>A (p.Glu191Lys) mutation, indicating HPP. Since diagnosis, she has had normal DEXA scans, tibial x-rays, and renal ultrasound negative for stones. Her course of treatment has mostly consisted of pain management with tapentadol 200 mg, gabapentin 300 mg, and buprenorphine 10 mcg/hour weekly transdermal patch. Her and her geneticist have discussed treatment with alkaline phosphatase replacement therapy and teriparatide--modified parathyroid hormone that promotes bone growth.

HPP is important to consider in patients with chronic bone pain, regardless of the consistency of alkaline phosphatase levels. It is also imperative to distinguish bone pain compared to pain of muscular origin, as seen with fibromyalgia. Diagnosis of HPP may provide more treatment options with teriparatide and alkaline phosphatase replacement.

163 Altered mental status in a patient with psychiatric history: medication noncompliance or medical etiology?

B Walterscheid*

N Eshak

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

An altered mental status (AMS) in patients with a past psychiatric history is often credited to medication non-compliance, substance use, or an exacerbation of their underlying psychiatric illness. Such biases could preclude these patients from necessary medical workups. We illustrate a case of a 58-year-old postmenopausal female whose AMS was initially attributed to medication noncompliance but was ultimately found to have vitamin B12 deficiency due to pernicious anemia.

The patient had visited the emergency room five times over the course of two weeks, presenting each time with a, in total, four-week history of progressively worsening symptoms of nausea, vomiting, weakness, diffuse abdominal tenderness, numbness of the extremities, poor balance, confusion, and memory loss. Her past medical history included hypothyroidism, anxiety with recurrent panic attacks, severe recurrent major depression, chronic pain, and reported polypharmacy. Initially, her symptoms were suspected to be due to her anxiety and withdrawal from polypharmacy—the patient was having difficulty paying for her medications, as her neuropathy impeded her work as a hairdresser. But at this fifth visit, laboratory studies revealed megaloblastic anemia with a hemoglobin of 9.7. Further workup and physical examination showed a low B12, elevated homocysteine and methylmalonic acid, and decreased sensation to vibration and pinprick. All of these are consistent with a diagnosis of pernicious anemia, and intrinsic factor antibody testing was positive. Our patient’s condition and polyneuropathy improved with monthly vitamin B12 injections.

This case illustrates the critical importance of holistically evaluating patients with AMS so to combat inherent biases against patients with past psychiatric histories. Aside from psychiatric illness exacerbation, the differential diagnosis in this patient population should include both external etiologies, such as toxic ingestion, substance use, and medication noncompliance, as well as intrinsic medical pathology, such as hypoglycemia or, as in this patient, autoimmune induced AMS.

164 A diagnosis that really gets under the skin: a case of pyoderma gangrenosum

KA Winter1*

A Winter1

J Burks2

L weatherly1,2

1University of Mississippi Medical Center, Jackson, MS and

2UMMC, University of Mississippi Medical Center, Jackson, MS, US, academic/hospital, Jackson, MS

Introduction

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that varies in presentation; the most common being ulcerative PG. Typically presenting as a rapidly progressive ulcer, ulcerative PG is often misdiagnosed as infection. Pathergy, the provocation of new lesions by trauma, has been described in patients with PG. It must be considered when suspected skin infections are resistant to antibiotics or worsen after debridement. Here we present a case of PG in a patient who failed to improve after numerous antibiotics and multiple surgical interventions.

Case Report

A 48-year-old female presented to clinic with cellulitis of her left lower extremity several weeks in duration caused by injury from a door. Her wound had progressed from a small erythematous area to a larger necrotic lesion flanked by erythematous skin. She was prescribed Augmentin and Bactrim with no response to treatment. She then presented to the hospital where she was started on intravenous clindamycin and received a debridement. The patient worsened and her antibiotics were broadened to vancomycin and cefepime. The patient’s wound further necrosed, leading to two additional debridements. Surgical cultures were negative for infectious organisms. Clindamycin was reinitiated followed by a fourth debridement. After sustained lack of response to antibiotics, the patient was started on oral prednisone due to concern for an autoimmune process and pathergy. On hospital day 14, pathology from a biopsy showed dense neutrophilic infiltrates associated with pyoderma gangrenosum. After initiating prednisone, the necrosis halted, and granulation tissue began forming. The patient’s wound continued to improve, and she was discharged on oral steroids.

Discussion

PG is a rare cause of skin ulceration that is commonly mistaken for infectious cellulitis. When confronted by an antibiotic-resistant, necrotizing wound that worsens with debridement, a clinician should always consider a non-infectious process such as PG as prompt treatment may avoid morbidity and complications of prolonged antibiotic therapy, unnecessary surgical procedures, and delayed wound healing.

165 Not all leg edema is cardiac-related: a case of leg edema secondary to breast cancer metastases

KA Winter1*

Y Ali2

1University of Mississippi Medical Center, Jackson, MS

2UMMC, University of Mississippi Medical Center, Jackson, MS

Introduction

Bilateral lower extremity (LE) edema is a physical exam finding most commonly seen in patients with heart failure, liver or renal disease, or chronic venous disease. Less commonly, it can be caused by direct compression of LE venous return. Excluding common causes of LE edema is vital to defining the underlying etiology. Here, we report an unusual presentation of LE edema caused by recurrent metastatic breast cancer.

Case Report

A 57-year-old female presented to the hospital with episodic vomiting. She had a history of right-sided triple-negative breast adenocarcinoma treated with mastectomy, radiation, and chemotherapy. Physical exam revealed bilateral LE edema and left axillary lymphadenopathy of one month in duration. Renal function tests were consistent with pre-renal failure; urinalysis and liver function tests were unremarkable. Her prior chemotherapy regimen included doxorubicin; thus, dilated cardiomyopathy was included as a potential cause of her edema. A chest x-ray revealed bilateral pleural effusions; however, a transthoracic echocardiogram showed a 65% ejection fraction, which was unchanged from prior studies. Additionally, no features of cardiomyopathy were recognized, making it an unlikely cause of the patient‘s edema. Abdominal computed tomography showed retroperitoneal adenopathy and infiltration of the right psoas muscle. We hypothesized that the muscular infiltration caused compression on the venous return from the LE. Thoracentesis of the patient’s pleural effusion revealed malignant cells. An excisional axillary lymph node biopsy was performed which showed recurrence of her previous breast adenocarcinoma. Oncology was consulted for further evaluation of the patient’s breast cancer recurrence.

Discussion

In the right clinical setting, rare causes of bilateral LE edema should be pursued. It is reasonable to consider the associated symptoms, significant clinical history, and physical exam to limit the possible etiologies. Initial workup should focus on excluding cardiac, renal, and hepatic causes. In patients with a strong suspicion for alternative etiology (e.g. with a history of cancer), further workup is warranted.

166 Occult multiple myeloma unmasked by an acute kidney injury

KA Winter1*

Y Ali2

1University of Mississippi Medical Center, Jackson, MS

2UMMC, University of Mississippi Medical Center, Jackson, MS

Introduction

Multiple myeloma (MM) is a monoclonal neoplastic proliferation of plasma cells. The most common presenting features include anemia, bone pain, renal failure, hypercalcemia, and recurrent infections. However, these symptoms are not always present, making the diagnosis of MM more challenging. Here we report an atypical presentation of MM that was unmasked by an acute kidney injury (AKI) secondary to sepsis.

Case Report

A 67-year-old male with type 2 diabetes mellitus and hypertension presented to the hospital with encephalopathy and urinary incontinence. Initial workup revealed a white cell count of 19.8k, creatinine of 2.21 mg/dL, alkaline phosphatase 210 units/L, and total bilirubin 2.93 mg/dL; hemoglobin and calcium were unremarkable. Blood cultures revealed Klebsiella pneumoniae. Abdominal computed tomography showed diffuse gallbladder wall thickening. Surgery evaluated and treated the patient‘s acute cholecystitis via cholecystostomy tube and a 7-day course of ceftriaxone. The patient‘s initial decline in renal function was presumed secondary to sepsis in conjunction with his pre-existing comorbidities; however, the patient’s kidney function continued to worsen, resulting in creatinine of 4.79 mg/dL prompting further workup. Fractional excretion of urea was found to be 32.8%, suggestive of pre-renal azotemia, and a 24-hour urine sample revealed nephrotic proteinuria of 3.8 grams. Serum and urine electrophoresis revealed a monoclonal light chain restriction. A bone marrow biopsy showed a neoplasm consistent with MM (>15% plasma cells). Treatment with cyclophosphamide, bortezomib, and dexamethasone was initiated. The patient was discharged with follow-up in hematology clinic.

Discussion

An AKI is defined as ‘resolving’ if a 25% decrease in creatinine from maximum is seen within 72 hours after diagnosis of the AKI. If injury to the kidney lasts longer than 7 days, it is considered acute kidney disease which warrants further evaluation. In a patient with an AKI unresponsive to treatment, additional causes should be evaluated. Even in the absence of typical clinical findings, MM should be considered in an elderly patient with nephrotic proteinuria and kidney dysfunction out of proportion to the inciting event.

Allergy/Immunology/Inflammation/Rheumatology

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
167 Rare case of systemic lupus erythematous

IR Burgos*

WD Marrero

C Rodriguez Negron

V Fonseca-Ferrer

HR Cintrón-Colón

Hospital Municipio de San Juan, Canovanas, Puerto Rico

Case Report

We present the case of a 33-year-old female with a medical history of gastritis who presented to the urgency department with periorbital swelling, generalized edema, and intractable abdominal pain that have progressively worsened in the last 2 months. Abdominal pain described as an intermittent and epigastric area. Symptoms included weight gain, arthralgia, generalized weakness, and dry skin. Physical examination nonpainful palpable lymphadenopathy on the left axilla, epitrochlear area, and anasarca with eye swelling and non-pitting edema. Stable GFR and hypoalbuminemia of 2.7 g/dl. Chest X-ray, TSH, Hepatitis, Syphilis, IgG, and Herpes 8 IGg negative. Urine analysis with no infectious process, with the presence of a protein of 30 mg/dl with urine cast. Collected 24-hour urine protein consistent with 272 mg of protein, ruling out nephrotic syndrome. Therapy with diuresis with the response of generalized edema. Recurrent angioedema episode occurred. At the time, an allergic reaction was suspected, therapy included corticosteroids, antihistamine, and epinephrine with no resolution and requirement of rapid sequence intubation for airway protection. Follow up labs showed leukopenia, hypoalbuminemia, and a new rash with an annular form that affected the abdomen and upper extremity. Other labs show positive ANA 1:40, Low Complement C3 and C4, elevated Sed rate and CRP, positive anti-Smith and anti-RNP. Left palpable axillary node pathology was consistent with follicular hyperplasia and prominent plasmacytosis. Bone marrow biopsy normocellular bone marrow, no evidence of metastatic cells, granulomas, or vasculitic skin Skin Biopsy showed subacute lupus rash, fulfilling SLE criteria as a definitive diagnosis. Also, CH50 12 positive result and C1 Esterase inhibitor pending to assess the acquired nature of her angioedema with and no vasculitis involvement with negative P ANCA and C ANCA and positive Anti -C1 inh antibody for an autoimmune-related type. Hypoalbuminemia consistent with probable Lupus protein-losing enteropathy given a recent diagnosis of Lupus with unexplained edema, a urine protein collection of 24 hours less than 0.5 gm, positive ANA pattern, and hypocomplementemia, with the positive response to steroids, still pending for fecal alpha 1 antitrypsin clearance test.

168 Tattoo sarcoidosis

IR Burgos*

V Fonseca-Ferrer

C Rodriguez Negron

Hospital Municipio de San Juan, Canovanas

Case Report

We report a 26-year-old male, no past medical history with 2 years of persistent itchy lesions that affected involved tattooing. He had a permanent tattoo for the last 5 years. The affected area with pruritus for a year progressed to a raised desquamating, and edematous lesion. One week before our evaluation started with bilateral ocular pain with symptoms of blurred vision and photophobia. Diagnosis of uveitis, with anterior chamber inflammation. Chest x-ray, Chest CT with no evidence of pulmonary fibrosis, and abdominal ultrasound with findings consistent with splenomegaly. CBC with thrombocytopenia of 143K, and no other abnormality. Biopsy consistent with non-caseating granulomatous dermatitis with a dense granulomatous infiltrate. He was initiated with oral prednisone and methotrexate with a good response.

Abstract 168 Figure 1

Non-caseating granulomatous dermatitis

169 Vasculitis v.s. thrombosis: a case of antiphospholipid syndrome

N Eshak*

B Walterscheid

A Wichmann

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX, US, Lubbock, TX

Case Report

A 38-year-old male smoker presented to our institution with worsening left lower extremity pain for the past week. He reported a gradually worsening left leg pain exacerbated by movement and partially relieved by analgesics. His past medical history was significant for a left pontine infarction 4 years earlier, and a similar episode in his right leg 3 years ago. CT angiography at the time revealed non-opacification of vessels beyond the mid-calf, a picture suggestive of Buerger’s disease, and he underwent right below-knee amputation (BKA). Clinical examination was significant for absent peripheral pulses and cold left foot.

The patient underwent peripheral angioplasty with the restoration of pulsations. Later he started to complain of left hip and foot pain. MRI showed multiple areas of avascular necrosis involving the femoral head, calcaneus, and talus (figure 1).

Buerger’s disease is an inflammatory disease characterized by thrombotic occlusion of distal small and medium-sized arteries and presents with distal limb ischemia in young male smokers. At this time it seemed that there was another underlying pathophysiology. The clinical picture seemed to fit more with a hypercoagulable state rather than vasculitis. A review of his medical records revealed a hypercoagulable workup 4 years earlier that was positive for Lupus anticoagulant (LA). Repeat LA was positive, establishing a diagnosis of antiphospholipid syndrome (APS), and warfarin was started.

APS is an autoimmune disease characterized by venous, arterial or small vessel thrombosis in the presence of LA or autoantibodies including anti-B2GPI, or anti-cardiolipin antibodies. The mainstay treatment for arterial thrombosis is life-long anticoagulation. The first clue to the diagnosis was the history of CVA, which is unlikely with Buerger’s, the presence of positive LA, and finally, the widespread thrombosis.

170 SLE presenting with acute heart failure and tamponade

N Eshak*

J Abdelmalek

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Systemic lupus erythematosus is an autoimmune disease characterized by multisystem involvement and the production of autoantibodies. SLE can involve almost any organ; cardiac involvement is one of the lesser-known and frequently overlooked manifestations.

We report a 33-year-old patient with a history of SLE, class V lupus nephritis, and pulmonary embolism. She presented to the ER complaining of 3 days worsening shortness of breath. Labs were significant for leucopenia and a high ESR at 90 mm/hr, serology for SLE showed elevated anti-ds DNA and consumed C3 and C4.

CT showed old pulmonary emboli, and cardiomegaly with a large pericardial effusion and an urgent echo revealed cardiac tamponade and a left ventricular ejection fraction of 20–25% with global hypokinesia. An emergency pericardial window was performed. Cardiac MRI showed no myocardial infiltration or enhancement.

In the setting of a SLE patient, with several clinical and serological markers of lupus activity, pericarditis and myocarditis with heart failure were attributed to a lupus flare.

Anti-heart failure measures were initiated, Rheumatology was consulted, and treatment for severe SLE flare was initiated with corticosteroids and cyclophosphamide.

At 3 months follow-up the patient was symptom-free, her TTE revealed an improved EF to 45%. It is important to recognize that pericarditis and myocarditis may be signs of a SLE flare and that treatment includes immunosuppressive therapy in addition to standard anti-failure measures.

171 Acute generalized skin eruptions in a patient with coronavirus disease-2019 pneumonia: severe generalized urticaria

F Etaee1*

M Eftekharian2

Z Hashemi2

N Niknezhad3

A Suggs4

T Naguib1

1Texas Tech University Health Sciences Center, Amarillo, TX

2Hamadan University of Medical Sciences, Hamadan, Iran (the Islamic Republic of)

3Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)

4Duke University, Durham, NC

Case Report

An 18 years old man was admitted with low-grade fever, dry cough, dyspnea, and skin eruptions. Upon admission, he tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A high-resolution computed tomography scan of the chest showed a diffuse bilateral ground-glass opacities consistent with coronavirus disease 2019 (COVID19) interstitial pneumonia.

A pruritic skin rash started 48 hours before admission, 1 day after respiratory symptoms, mostly on his trunk. On examination, a generalized urticarial skin rash characterized by erythematous, smooth, slightly elevated papules and wheals, associated with severe pruritus was detected. The patient reported neither similar episodes in the past nor allergies to drugs or foods. Further, he had not taken any new medication recently. Dermatology consultation confirmed the diagnosis of generalized urticaria due to COVID19.

White blood cell count was normal (no lymphopenia or lymphocytosis or eosinophilia), C-reactive protein was 12.1 mg/dL, but liver enzymes were normal. Systemic treatment with intravenous dexamethasone, oral hydroxyzine, oral famotidine, in addition to antiviral therapy was started. In the subsequent days, urticaria and his respiratory function improved gradually, and he was discharged on daily loratadine.

172 A rare skin complication of hydroxychloroquine therapy for positive coronavirus disease 2019 infection: acute generalized exanthematous pustulosis

F Etaee1*

N Ghanei2

A Suggs3

T Naguib1

1Texas Tech University Health Sciences Center, Amarillo, TX

2Shahid Sadoughi University of Medical Sciences, Yazd, Iran (the Islamic Republic of)

3Duke University, Durham, NC

Case Report

A 49-year-old woman with a past medical history of hypertension presented to the emergency department for shortness of breath, low-grade fever, and dry cough. She was tested for COVID-19 and it was positive. Due to normal oxygen saturation, she received a 5-day treatment with oral azithromycin and Hydroxychloroquine (HCQ) 400 mg orally twice daily on the first day, then 400 mg once daily for the next 4 days. 6 days after the completion of the treatment, the patient developed a pruritic rash on her face and neck. Over the next 5 days, she developed widespread erythema, scale, and pustules covering more than half of her body surface area. She had prominent facial and trunk involvement. She complained of fever (38.1°C (100.6°F)), chills, and generalized aches. She had a white blood cell count of 22,700 with a left shift and no eosinophilia. Her septic workup was negative. ESR was 35. Two punch biopsies and swabs of the pustules were taken. The patient was started on intravenous methylprednisolone. Intravenous vancomycin was started empirically with suspicion of bacterial skin superinfection. The patient started to better clinically, and her skin showed evidence of desquamation and healing. Both biopsy reports showed intraepidermal collections of neutrophils as well as subcorneal collections consistent with a diagnosis of acute generalized exanthematous pustulosis. There was no parakeratosis to suggest psoriasis. Finally, the patient was discharged home on a tapering dose of oral prednisone. After 4 weeks, her rash resolved.

173 Multisystem inflammatory syndrome in children: a new challenge in the covid-19 pandemic

B Ferguson*

MD Kala

DG Hodge

VA Harrison

University of Mississippi School of Medicine, Jackson, MS

Case Report

Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe inflammatory syndrome temporally associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although MIS-C is rare, clinicians should have a high index of suspicion in febrile children with evidence of systemic inflammation because prompt intervention is essential. MIS-C affects older children and adolescents and is defined by the CDC as fever, laboratory evidence of inflammation, and multisystem organ involvement in an individual with current or recent SARS-CoV-2 infection or exposure to a suspected or confirmed case within 4 weeks of onset of symptoms. MIS-C causes severe systemic inflammation with complications such as cardiac dysfunction, shock, and even death. This case highlights the diagnosis and management of MIS-C in a healthy child with preceding SARS-CoV-2.

A 7 year old male presented with fever and abdominal pain for one week. Past medical history was significant for SARS-CoV-2 infection diagnosed one month prior. Exam was significant for conjunctivitis and abdominal distention and tenderness, but no mucocutaneous changes or rash. Laboratory studies revealed evidence of systemic inflammation with elevated D-dimer, Ferritin, CRP, and ESR. Chest XR revealed bilateral perihilar and basilar opacities with small bilateral pleural effusions. Pro-BNP was elevated. EKG revealed sinus rhythm. Echocardiogram was normal. Presentation was concerning for MIS-C. Although Kawasaki disease was a consideration, the patient did not meet diagnostic criteria. Multiple pediatric subspecialists were consulted. The patient was treated with supportive care including IV fluids and supplemental oxygen as well as IV Methylprednisolone 500 mg daily for 3 days, Lovenox 0.5 mg/kg twice daily, and Aspirin 45 mg/kg daily. With these interventions, the patient stabilized and defervesced. He was discharged on a Dexamethasone taper, Lovenox for one week, and Aspirin for 6 weeks.

MIS-C is a rare, but severe and potentially life-threatening syndrome. The diagnosis is challenging given the variety of presentations and potential features of other inflammatory or infectious conditions. However, early diagnosis and treatment is crucial to prevent associated morbidity and mortality.

174 Reversible cerebral vasoconstriction syndrome: an underdiagnosed cause of neurovascular disease

CE McGill*

S Moore

A Cecchini

R Burgess

ETSU, Kingsport, TN

Case Report

Transient ischemic attacks, cerebrovascular accidents, and intracranial hemorrhages are a common reason for admission to the hospital. The cause or inciting factor for these events is often not found. Reversible cerebrovascular vasoconstriction syndrome (RCVS) is an under-recognized and often misidentified cause of these disease processes (Nesheiwat O, 2020). Described below is a case of RCVS that was misidentified as a Primary Angiitis of the Central Nervous System (PACNS) due a positive antineutrophil cytoplasmic antibodies (ANCA).

A 57 year old female presented to the emergency department with a one hour history of headache, weakness, facial droop, and slurred speech. She had recently returned from a trip to Utah where she had been hiking at a high elevation, and taking an over the counter multi-symptom sinus medication. Imaging on admission revealed a right basal ganglia hemorrhage with extension into the lateral ventricle, and vascular irregularity in multiple arterial branches posteriorly. Lack of significant hypertension on admission lead to investigation of other causes of the intracranial bleeding. The patient was noted to be ANCA positive with a ratio of 1:80, but testing for complements C3, C4 cryoglobulins, hepatitis, human immunodeficiency virus, rapid plasma reagent, Lyme disease, Rocky Mountain spotted fever, and peripheral smear all without significant abnormality. Positive ANCA with the absence of infection raised concern for primary central nervous system vasculitis. The patient was treated with high dose 1 mg/kg of intravenous methylprednisolone for 4 days, then transitioned to a long taper of oral prednisone starting at 60 mg daily, and discharged.

The patient was then evaluated in the rheumatology clinic for follow up. Further elicitation of history revealed absence of any hemoptysis, nasal crusting, renal disease, uveitis, fever, joint pain/swelling, or rash to suggest small vessel vasculitis which are associated with ANCA positivity. Labs revealed negative ANCA, MPO, and PR-3. It was noted that ANCA does not play a role in the diagnosis of PACNS (Daniel Strunk, 2019). The patient was referred to a vasculitis clinic for a second opinion, and subsequently diagnosed with RCVS due the multiple areas of vasospasm on angiogram.

175 Overlap syndrome complicated with diffuse alveolar hemorrhage

F Mubeen1*

A kamat1

N Davey-Ranasinghe1,2

1Texas Tech University Health Sciences Center, Amarillo, TX

2Amarillo Center for Clinical Research, Amarillo, TX

Case Report

Overlap syndromes in rheumatology are a group of conditions that have clinical features and meet classification criteria for more than one well-defined rheumatic disease. While Rhematoid arthritis(RA) is commonly seen with lupus and other autoimmune diseases, Anti-neutrophil cytoplasmic antibody(ANCA) associated vasculitis (AAV) rarely presents in association with other immune mediated disease. AAV has significant morbidity and mortality and has worse outcome with delay in diagnosis. We describe a case of RA with AAV presenting as pulmonary renal syndrome.

47 year old lady with known untreated severe RA with high titer anti citrullinated protein(CCP) antibodies, untreated chronic vasculitis with cutaneous involvement and persistently positive PR-3 antibodies presented to ED with one week history of lethargy, poor oral intake and oral sores. In addition she had a dry cough and mild dyspnea. She was found to have acute kidney injury, lactic acidosis and bilateral air space disease on chest imaging and was admitted for sepsis secondary to pneumonia and treated with antibiotics. Later she was intubated and put on mechanical ventilation for worsening acute hypoxemic respiratory failure. Interim she had hemoptysis, a diffuse maculopapular rash and her renal function deteriorated with evidence of red blood cells in her urine. She was seropositive for ANCA-PR3. A renal biopsy showed crescentic glomerulonephritis. Bronchoscopy had evidence of diffuse alveolar hemorrhage(DAH). She was started on pulse steroids and rituximab with pneumocystis pneumonia prophylaxis and mycophenolate. Due to ongoing DAH and severe blood loss anemia plasmapheresis was started. Her stay was complicated with streptococcal bacteremia. Despite aggressive management the patient continued to worsen and family decided to withdraw care to ally patient’s suffering.

ANCA associated vasculitis is rarely associated with other autoimmune diseases. However, there are previous case reports of AAV overlapping with RA in which renal involvement was commonly seen, though DAH has not been described. Pulmonary renal syndrome in untreated RA patient definitely warrants further investigations to rule out other immuno medicated disease to guide further management.

176 Henoch-schonelin purpura presenting in an adult

R Musa*

S Moore

East Tennessee State University, Johnson City, TN

Case Report

Henoch-Schönlein Purpura (HSP) is a self-limiting small vessel vasculitis mediated by IgA deposition that primarily affects children and is usually preceded by an infectious process. It has also been known to affect adults where it typically has a more complicated course. This is especially important since the incidence of renal insufficiency develops in almost 50% of adult patients2 and up to 36% may suffer permanent renal damage3. We report a 25 year old male who required hospitalization for worsening rash without preceding evidence of infection and was found to have leukocytoclastic rash and diagnosed with Henoch-Schonlein Purpura. He presented to an urgent care center and was given a short course of prednisone which helped with the swelling but the rash continued to progress. It initially appeared on the left heel which spread bilaterally upwards towards his waist, associated with bilateral foot and hand swelling. Patient was then seen in the ER with elevated blood pressure (197/111 mmhg), HR (114/min, NSR). On physical examination, palpable rash was evident on anterior surface of lower extremities extending up to the abdomen below the umbilicus. Blood work showed elevated white cell count (15.9), normal Hgb, platelets, BUN and Creatinine. Moderate proteinuria with hematuria was noted on urinalysis. ESR, CRP, ANA, ANCA, Rheumatoid factor, CCP, SSA, SSB, cryoglobulins and HCV serology were within normal limits. Skin biopsy of one of the lesions on left lower extremity showed leukocytoclastic vasculitis. He received IV methylprednisolone 1 g for 3 days and later discharged on prednisone 60 mg/day. Subsequently, he was followed up in the rheumatology office where he was found to have progressive proteinuria.

Full case report and list of references available.

177 An atypical initial presentation of diffuse alveolar hemorrhage and systemic lupus erythematosus in an adult male

DS Nichols1*

H Jhaveri1

S Streit2

M Kumar2

1University of Florida Health, Gainesville, FL

2University of Florida Health Jacksonville, Jacksonville, FL

Case Report

Systemic Lupus Erythematosus (SLE) is notorious for its diffuse and variable manifestations. Initial presentations of SLE often perplex clinicians, leading to diagnostic and treatment delays. This is especially true in males with atypical presenting symptoms. We herein report a case of a 27-year-old Indian male with no history of SLE who presented to the hospital with one week of dysphagia, myalgia, and a rash. Two months prior to presentation, he was treated for suspected erythema multiforme at an outside hospital and was discharged on a short course of oral steroids. Following admission at our hospital, initial laboratory workup revealed pancytopenia, and after 24 hours, he became hypotensive and tachycardic, with new-onset respiratory distress requiring ICU-level care. A diagnosis of DAH was made with bronchoscopy and serology demonstrated an ANA titer of 1:320, dsDNA of 235 IU/mL, and anti-Smith antibodies greater than 8.0 AI, confirming SLE. Through reporting this case, it is our hope that increased awareness of atypical SLE manifestations may prevent a severe complication, such as DAH, from occurring. It is especially important to maintain high-clinical suspicion for SLE in all patients presenting with diffuse and seemingly unrelated symptoms, regardless of sex and ethnicity.

Abstract 177 Figure 1

Rash sparing the nasolabial folds (posted with permission).

178 Hashimoto’s thyroiditis and renal transplant failure

B Sigman1*

D Linder1

W Bollag1,2

J Waller1

SL Baer1,2

AA Mohammed1

S Tran1

M Kheda1

V Spearman1

C Isales1

B Siddiqui1

1Augusta University, Augusta, GA

2Augusta VA Medical Center, Augusta, GA

Purpose of Study

Hashimoto’s Thyroiditis (HT) is a common autoimmune disorder of the thyroid and cause of hypothyroidism. The potential effects of HT on long-term renal transplant survival have not been fully examined. To study this, we examined renal transplant patients and compared the time from transplant to failure in patients with and without HT.

Methods Used

We queried the United States Renal Database for patients initiating end-stage renal disease (ESRD) services between January 1, 2005 and December 31, 2014. Patients aged 18 and older with at least one renal transplant were included. Patients that experienced acute renal transplant failure, defined as rejection occurring within 14 days of initial transplant, were excluded. Kaplan-Meier (KM) estimates of first renal graft survival probability and a multivariable Cox proportional hazards model (CPH) of time to graft failure were used to assess differences in graft survival by HT status.

Summary of Results

Among the 90,301 patients meeting study inclusion criteria, 144 were identified as having HT prior to renal transplant. Compared to those without HT, HT patients were more likely to be female (77.1% vs. 38.6%; p<0.001), White (85.4% vs. 69.8%; p=0.035), and diagnosed with cytomegaloviral (CMV) disease (27.1% vs. 17.1%; p=0.038). ESRD patients with a HT diagnosis prior to initial renal transplant had a significantly reduced graft life expectancy (p<0.001) and a significantly increased adjusted hazards ratio (aHR) for graft failure compared to those without HT (aHR=1.44; 95% CI 1.05–1.99). An increased risk of graft failure was also associated with being Black vs. White (aHR=1.60; 95% CI 1.54–1.66) and CMV disease (aHR=1.81; 95% CI 1.74–1.88).

Conclusions

In ESRD patients with renal transplant, a prior HT diagnosis was associated with increased risk of renal graft failure and reduced graft life expectancy compared to those without HT. Further studies may reveal whether the specific autoimmune mechanism underlying HT or currently unknown factors explain these observed associations between HT and renal transplant failure.

179 Inflammatory pseudo-tumor in a patient with systemic lupus erythematosus

P Tiwari*

C Aguiar

M Aguiar

Eastern Virginia Medical School, Norfolk, VA

Introduction

Inflammatory Pseudotumor (IPT) of the lymph node is a syndrome of lymphadenopathy characterized histologically as a non-neoplastic proliferation of various cells, here we report a case of IPT associated with SLE.

Case Report

A 17-year-old old African American female presented with a 1-month history of subjective fevers, decreased appetite, 20-pound weight loss and lymphadenopathy. Laboratory studies were notable for a white blood cell count 3.9 x103ul, hemoglobin 9.6 gm/dl, platelet 401 x103ul, absolute neutrophil count 2874ul, erythrocyte sedimentation rate >120(mm/hr), c-reactive protein 3.3 mg/dl and lactate dehydrogenase 795 unit/liter (nl <670) with a normal uric acid 3.2 mg/dl. Infectious work-up including Ebstein Barr Virus (EBV), Cytomegalovirus, Bartonella, Tuberculosis and HIV studies did not reveal acute infection. A CT scan of the neck and chest was notable for multiple enlarged cervical, supraclavicular and axillary lymph nodes, and a 5 mm pulmonary nodule A left supraclavicular lymph node biopsy showed reactive lymphoid hyperplasia with prominent capsular and trabecular fibrosis, fibroblastic and vascular proliferation and mixed inflammatory cell infiltrate including eosinophils and many plasma cells consistent with Inflammatory Pseudotumor. Laboratory studies came back notable for a positive Anti-Nuclear Antibody (ANA) 1:2560 (speckled pattern), anti-double stranded DNA (dsDNA) 61 IU/ml (nl <4), anti-Sjogren’s A (>8), Anti- Smith (>8), Anti-RNP (>8) with negative anti-Sjogren’s B and normal complements 3 and 4 (97 mg/dl and 23 mg/dl respectively). The diagnosis of SLE with Inflammatory Pseudotumor of the lymph node was made. The patient was started on Prednisolone, Hydroxychloroquine and Mycophenolate Mofetil and on follow-up had appropriate resolution of symptoms.

Discussion

Systemic Lupus Erythematosus pathology usually reveals non-specific lymphoid follicular hyperplasia, scattered immunoblasts, plasma cells and increased vascularity (2). Inflammatory Pseudotumor of the lymph node has been reported in Rheumatoid Arthritis (3), but its presence in patients with SLE has not been previously reported. The unique finding of IPT in our patient with SLE highlights evaluating for autoimmune conditions that can co-exist.

180 Dehydrated human amnion/chorion membrane allograft for treatment of resistant pyoderma gangrenosum

AS Weissman*

VS Patel

W Moore

Augusta University, Augusta, GA

Case Report

Pyoderma gangrenosum (PG) is a rare, sterile, inflammatory neutrophilic dermatosis that is painful with necrotizing ulcerations. It can be idiopathic or in association with systemic disease such as PG, acne, hidradenitis suppurativa (PASH) syndrome. PASH syndrome itself is rare, consists of multiple neutrophilic dermatoses, and is thought to be caused by an underlying genetic predisposition. Due to recurrence and poor healing, treatment for PG ranges from wound care to topical and oral medications to surgical procedures. Usually, a combination of most, if not all, of these therapies are necessary to resolve PG. Some patients, however, are resistant to many of the currently used treatment options and live with debilitating pain and extensive wound care regimens. Human amniotic tissue has been used to treat a variety of wounds over the last century. However, it has rarely been utilized in the setting of treatment resistant PG, with only two other cases reported in the literature to our knowledge. The patient presented in this case developed worsening PG in the setting of PASH syndrome and systemic lupus erythematous that was refractory to multiple treatment methods. After undergoing four allograft treatments with dehydrated human amnion/chorion membrane (dHACM) (figure 1), the patient began to notice drastic improvements of her PG. This case emphasizes the success of dHACM in treating PG and how it should be considered for patients whose PG does not resolve with more traditional treatments.

Abstract 180 Figure 1

Pyoderma gangrenosum in response to four dHACM allograft therapy treatments over the span of four months. A) First treatment complete. B) Second treatment complete. C) Third treatment complete. D) Fourth treatment complete.

Cardiovascular

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
181 A rare pheochromocytoma presentation: prolonged qt interval with ventricular fibrillation cardiac arrest

J Abdelmalek*

M Elmassry

M Abohelwa

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Pheochromocytoma is mostly an adrenal gland benign catecholamine secreting tumor. Patients with pheochromocytoma usually present with a triad of episodic headaches, sweating and tachycardia. Atypical presentations have been described in literature, however very few cases have presented with cardiac repolarization abnormalities, QTc interval prolongation and ventricular fibrillation cardiac arrest.

Here we report a 26-year-old female with past history of chronic headaches, anxiety and panic attacks. Patient was found unresponsive and pulseless by EMS, cardiac resuscitation was performed, initial rhythm was ventricular fibrillation and patient achieved ROSC after 17 minutes.

At hospital patient was later extubated and had good neurological recovery, however she continued to have persistent hypertension initially requiring nicardipine drip in the medical ICU. Cardiac echocardiography and ischemic work-up were unremarkable. Her EKGs showed prolonged QTc intervals up to 655 ms. Abdominal CT scan showed a 5 cm left adrenal incidentaloma, that measured 44 Hounsefield units. Plasma metanephrines were increased by 27 folds.

Patient was diagnosed with pheochromocytoma, she was initially treated with alpha blockers that were later titrated, and then beta-blockers given her long QTc on EKGs.

She underwent surgery for adrenalectomy and pathology proved benign adrenal pheochromocytoma.

Follow-up EKGs showed normalized QTc intervals.

Work-up of patients with QTc interval prolongation, especially those who present with fatal cardiac arrhythmias is of crucial importance. Moreover, pheochromocytoma in these patients should always be suspected when alarming clinical presentation is present.

182 The role of C-reactive protein to measure periodontal inflammation producing coronary artery disease and other inflammatory processes

PI Altieri1,2*

N Escobales1

V Covas1

R Sánchez1

C Quiñones1

HL Banchs1,2

1University of Puerto Rico Medical Sciences Campus, San Juan

2Cardiovascular Center of Puerto Rico and the Caribbean, San Juan, Puerto Rico

Purpose of Study

To explain the importance of measuring C-Reactive Protein (CRP) in all diseases which includes inflammation, especially obesity, Type 2 diabetes mellitus, hypertension and periodontal inflammation, as an important contributing factor in the progression of inflammation in different conditions producing tissue damage in a Hispanic country.

Methods Used

Literature and Puerto Rican experience.

Summary of Results

Our work in the heart center shows that 67% of patients (P) have metabolic syndrome (MS) with a rate of 20% having acute myocardial infarction or variant of coronary artery disease. This population shows a positive CRP (30%) with an increase of circulating monocytes migrating to the infarcted myocites, probably at those stages-macrophages due to changes of monocytes to macrophages. More than 80% have moderate to severe periodontal disease.

Conclusions

The acute reactant CRP is a well-known acute inflammatory protein during cardiovascular events as acute infarction and variants of others inflammatory diseases. This protein, as well as other cytokines, appears in 24–45 minutes after the event or exists chronically. The role of statins, ASA and omegas like omega 3 or 7; and other treatments will be discussed as a way to improve these abnormalities reflected as (+) CRP. It is important to check CRP in all P. with periodontal disease to find a population of high risk which attacks the immunological system, including infiltration of monocytes-macrophage system, affecting the coronary circulation and myocardial system.

183 The role of periodontal disease in coronary artery disease in a hispanic population (PUERTO RICO)

PI Altieri1,2*

N Escobales1

K Didriksen1

R Sánchez1

C Quiñones1

HL Banchs1,2

1University of Puerto Rico Medical Sciences Campus, San Juan

2Cardiovascular Center of Puerto Rico and the Caribbean, San Juan

Purpose of Study

The purpose of this report is to describe the role of Periodontal Disease (PD) in Coronary Artery Disease (CAD) in a Hispanic country, Puerto Rico.

Methods Used

Literature and Puerto Rican experiences were reviewed and will be discussed.

Summary of Results

PD produces inflammatory disease by bacterial infection in the gingiva. This factor PD activates an inflammatory process affecting the CAD cascade inducing myocites and endothelial cells to be damage by this inflammatory process, producing damage to the endothelial lining. The incidence of gingival disease in the Puerto Rican population (P) in this group is around 40%; of this group 80% will develop periodontal disease, which include bacteria and Cytokines. The product of this process is severe damage to the gingiva, producing an active inflammatory disease, which will activate the cytokines system, reducing IL-10, producing CAD.

Conclusions

PD is related to an inflammatory process, which will activate the CAD process, producing tissue infarcts and inflammation. The daily use of resolving and Omega 3 applied to the gingival tissue is useful in the prevention of gingival and periodontal disease, reducing the incidence of CAD and other inflammatory problems. At present the dental and cardiology clinic is attacking aggressively this problem to keep a relatively low incidence of CAD in the Island. This incidence is 20–30% less than in the U.S.A. due to genetic factors and an aggressive program to reduce the inflammation in this population by local application of statins and the omega factors like omega 3 or 7 to the gingival tissue.

184 The use colchicine in ischemic heart disease

AK Butt1*

B Cave2

M Maturana1

RN Khouzam1

1The University of Tennessee Health Science Center Memphis, Memphis, TN

2Methodist Le Bonheur Healthcare, Memphis, Memphis, TN

Purpose of Study

To review the literature and summarize findings of clinical research studies investigating the use of colchicine in stable ischemic heart disease, acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI) with stenting.

Methods Used

We identified relevant literature by conducting a search of the databases from PubMed and United States National Library of Medicine clinical trial database (http://www.clinicaltrials.gov) using the terms ‘colchicine’ AND ‘cardiovascular disease’ OR ‘coronary artery disease’ OR ‘acute coronary syndrome’ OR ‘ischemic heart disease’.

Summary of Results

Inflammation is a major contributing factor leading to the development and progression of atherosclerosis and ischemic heart disease (IHD) and therefore represents a potential target for treatment with anti-inflammatory drugs. Colchicine is a well-known medication indicated for the treatment for inflammatory diseases such as acute gout and recurrent pericarditis. Various clinical and experimental trials have investigated the activity of colchicine in IHD. The LoDoCo and LoDoCo2 trials studied colchicine in chronic coronary disease and both demonstrated a significant reduction in cardiovascular events as compared to placebo. Studies such as the COLCOT trial showed that colchicine significantly decreased the incidence of future cardiovascular events in patients post ACS. For coronary angioplasty and PCI, colchicine has shown mixed results in trials so far. The encouraging results in recent clinical trials have generated considerable interest in further exploration of the potential indications of colchicine in treating and preventing IHD.

Conclusions

Current evidence shows that inflammation is a critical component in the pathogenesis of coronary atherosclerosis. Therapy with colchicine directed against inflammation may have a role in treating and preventing IHD. Future studies are highly anticipated to provide stronger evidence regarding the potential role of this low-cost drug in reducing morbidity and mortality associated with IHD.

185 The BCL-2 nineteen kilodalton interacting protein 3 modulates mitochondrial oxidative capacity and metabolism in rat systolic heart failure model

AH Chaanine*

P Delafontaine

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Previously we have shown that the Bcl-2 nineteen kilodalton interacting protein 3 (Bnip3) improved mitochondrial morphology and myocardial contractile function in a rat pressure overload systolic heart failure (SHF) model. BNIP3 expression increased in human SHF as well. The purpose of the study was to assess BNIP3 effect on myocardial proteome, focusing on changes in mitochondrial proteome.

Methods Used

Shotgun proteomic approach using tandem mass tags liquid chromatography mass spectrometry was performed in left ventricular myocardium tissue of Sham (n=3), SHF treated with control adeno-associated virus encoding for Luciferin ShRNA (AAV9.ShLuc, n=3), and SHF treated with AAV encoding for BNIP3 ShRNA (AAV9.ShBNIP3, n=4). Scaffold software was used for analysis of the proteomic data using the permutation test and Qlucore software was used for generation of heatmaps and data presentation. STRING database was used for protein networks and reactome pathways analysis. Some of the changes in reactome pathways were also verified by Western blotting.

Summary of Results

A total of 484 mitochondrial (mt)-proteins were identified, of which 12 (2.5%) increased and 348 (72%) decreased in abundance in SHF + ShLuc relative to Sham. 229/348 (66%) mt-proteins that decreased in SHF + ShLuc were related to reactome pathways involved in the citric acid (TCA) cycle and respiratory electron transport chain (ETC) system, Pyruvate, fatty acid and amino acid (AA) metabolism and branched chain amino acid (BCAA) catabolism. The remainder 119 (34%) belonged to reactome pathways related to mt-translation elongation and termination and mt-calcium entry and import. The gene delivery of AAV9.ShBNIP3 increased the abundance of 50/348 mt-proteins; 34 of which involved in TCA cycle, ETC system, pyruvate and AA metabolism and BCAA catabolism. Changes in expression of the ETC complexes were verified by Western blotting.

Conclusions

mt-proteins are predominantly decreased in abundance in SHF. The gene delivery of AAV9.ShBNIP3 in rat SHF model improved mt-oxidative capacity and metabolism as noted above. BNIP3 constitutes a potential therapeutic target for SHF.

186 Echocardiographic analysis of right heart disease in patients with pulmonary hypertension and cardiomegaly

B Daines*

O Hosseini

S Rao

SK Prieto

J Abdelmalek

M Elmassry

P Sethi

V Test

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Echocardiography is an imaging technique used as the preferred method for left ventricular evaluation in patients with heart failure. Echocardiography also provides information about the right heart which has both diagnostic and prognostic value. Measurement of ventricular strain provides information about myocardial muscle function even in patients with normal ejection fractions. Cardiomegaly in patients with pulmonary hypertension (PH) may have important clinical implications. We analyzed a cohort of patients with PH to determine the associations between cardiomegaly and right heart disease.

Methods Used

This cohort includes 131 patients referred to the pulmonary vascular disease clinic at Texas Tech University Health Sciences Center in Lubbock, Texas between January 1, 2019 and May 20, 2020. Patients with appropriate indications underwent right heart catheterization. Sixty patients had echocardiography prior to catheterizations. These echocardiograms were reevaluated to determine right heart strain. Information, including demographics, catheterization data, echocardiography data, and laboratory results, was analyzed.

Summary of Results

The mean patient age was 62.6 ± 14.8 with 58.3% women. Patients were grouped based on the presence of cardiomegaly on chest x-ray. The average right ventricular free wall strain was -18.0 ± 5.4 in patients with cardiomegaly and -18.5 ± 4.8 in patients without cardiomegaly. Patients with cardiomegaly had greater right ventricular (56.2 ± 28.4 ml/m2 vs 47.6 ± 21.3 ml/m2) and atrial (42.9 ± 20.5 ml/m2 vs. 34.4 ± 22.2 ml/m2) volume indices. Patients with cardiomegaly had increased right ventricular systolic pressures (67.6 ± 24.4 mmHg vs 50.8 ± 19.8 mmHg) and right atrial pressures (13.5 ± 6.9 mmHg vs. 8.5 ± 5.0 mmHg).

Conclusions

Patients with PH and cardiomegaly had slightly decreased right ventricular strain and had increased right heart pressures and volumes. These observations suggest that patients with PH and cardiomegaly are more likely to have right heart disease and that their evaluation should include comprehensive right heart assessment with echocardiography, including strain measurements.

187 Evaluating exercise response variables of children with pectus excavatum

C DeVol*

M Darwish

A Hyde

R Philip

1LeBonheur Children’s Hospital, Memphis, TN

2The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Purpose of Study

Relationship between severity of pectus excavatum and cardiopulmonary changes during exercise.

Methods Used

Retrospective review of cardiopulmonary exercise testing of 121 patients aged 0 to 19 with pectus excavatum referred to the exercise physiology laboratory over a 5-year period. Baseline parameters were collected including Haller index and pulmonary function tests. Additional physiologic variables related to aerobic capacity, cardiovasular response, and ventilatory response were assessed with exercise stress testing. These parameters were then compared to the Haller index to see if there was any correlation between patient with a mild/moderate (2.0–3.5) and severe Haller Index (>3.5) using Two-Sample T-Test and Spearman Correlation.

Summary of Results

See tables.

Abstract 187 Table 1
Abstract 187 Table 2

Conclusions

There is a negative correlation between Haller index and FVC, FEV1, heart rate reserve, and vetilatory reserve. When comparing mild/moderate Haller index to severe there is no significant difference between FVC, FEV1, and heart rate reserve. However patients with a Severe Haller Index tended to have a statistically significant lower ventilatory reserve.

188 A rare case of seckel syndrome presenting with complete heart block

M Elmassry1*

M Abohelwa1

J Abdelmalek1

E Elgwairi1

M Elmassry2

G Del Rio-Pertuz1

D Swaminath3

1Texas Tech University Health Sciences Center, Lubbock, TX

2Leicester Royal Infirmary, Leicester, UK

3Texas Tech University System, Lubbock, TX

Introduction

Seckel syndrome is a rare (<1:10,000 live births) autosomal recessive disorder characterized by facial dysmorphic features and known as Bird-Headed Dwarfism. Only about 100 cases were reported in the literature. We present a case of Seckel syndrome presenting with Complete Heart Block (CHB).

Case presentation

A 21-year-old female with Seckel syndrome and epilepsy who presented with status epilepticus. She was hypotensive and bradycardic in the 20s. Labs showed AKI (Creat 0.8, baseline 0.5) with K 6.4. EKG showed CHB. She received IV Calcium chloride, IV Fluids, Dopamine drip, and placed on transcutaneous pacer with no response. A transvenous pacemaker was inserted prior to admission to the PICU given her very small size (57 lb). Electrolytes normalized with persistent CHB. Transthoracic Echo was unremarkable. A suitable permanent pacemaker (PPM) for her size was unavailable at our facility and she was transferred to UTSW Medical Center in Dallas where she got a PPM and was discharged home in stable condition.

Discussion

Seckel syndrome is a rare autosomal recessive disorder characterized by, dwarfism, intellectual disability, facial dysmorphic features, microcephaly, and ‘beak-like’ protrusion of the nose. Cardiovascular manifestations are very rare in this disease with less than 10 cases in the literature with cardiac manifestations. Congenital cardiac anomalies were reported in few cases (e.g. Tetralogy of Fallot, Tricuspid atresia, Atrioventricular canal defect, PDA, and ASD). Moyamoya-like Vasculopathy was reported in 1 case. Severe sinus bradycardia requiring a pacemaker was also reported in one case with an unclear mechanism. No arrhythmias or high degree AV block were reported. To our knowledge, our case is the first case of CHB to be reported in association with Seckel syndrome.

Conclusion

CHB may be a new association with Seckel syndrome. More cases need to be studied to further understand this potential association.

189 Shock without wires: a look at subcutaneous implantable cardioverter-defibrillator compared to transvenous implantable cardioverter-defibrillator for ventricular arrhythmias

KC Guice1*

J Raja1

M Oberoi2

R Khouzam1

1The University of Tennessee Health Science Center College of Medicine, Memphis, TN

2University of South Dakota Sanford School of Medicine, Sioux Falls, SD

Purpose of Study

Sudden cardiac death is a major cause of mortality in the US. Transvenous ICD is traditionally used for the prevention of ventricular arrhythmias. It is also associated with complications like pneumothorax and tamponade. This abstract aims to review subcutaneous ICD (S-ICD) as an alternative with reduced complications.

Methods Used

We conducted a Medline search of ‘Subcutaneous,’ ‘ICD,’ and ‘ventricular tachycardia or fibrillation (VT/VF)’ to identify trials published before October 5, 2020, for inclusion in this review. Major practice guidelines, trial bibliographies, and reviews were examined to ensure the inclusion of relevant trials. The following section reviews data from trials to review the efficacy of S-ICD for termination of VT/VF.

Summary of Results

The S-ICD system consists of a pulse generator positioned over the sixth rib between the midaxillary and anterior axillary line and a tripolar parasternal electrode with the proximal and distal sensing electrodes positioned adjacent to the xiphoid process and manubriosternal junction. The conversion of the efficacy of the S-ICD after the first shock is 88%-90.1% and 98.2%-100% after 5 shocks based on the current evidence. The device also has a 99% complication-free rate at 180 days. The PRAETORIAN trial showed non-inferiority of the S-ICD to transvenous ICD with device-related complications.

Conclusions

S-ICD advantages include no fluoroscopy and decreased complications. The limitations are a lack of pacing abnormalities, increase in inappropriate shocks, and non-reliability with baseline T wave abnormalities. Thus, S-ICD can be considered as an alternative to transvenous ICD in patients with a need for defibrillator therapy but with no need for pacing.

Abstract 189 Table 1

Conversion efficacy, side effects of subcutaneous ICD

190 Cardiovascular safety reporting in breast cancer clinical trials

A Hamid1*

J Ruckdeschel1

MS Khan1

A Tharwani2

AA Oshunbade1

RK Kipchumba1

C Thigpen1

SD Anker3

GC Fonarow4

ME Hall1

J Butler1

1University of Mississippi Medical Center, Jackson, MS

2Cleveland Clinic, Cleveland, OH

3Georg-August-Universitat Gottingen, Gottingen, Germany

4University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA

Purpose of Study

Several chemotherapies have been associated with cardiovascular (CV) harm in early phase clinical trials. However, some CV harms do not manifest until later phase (2 and 3) trials. To limit inter-disease variability, we focused on breast cancer. Thus, we assessed reporting of CV safety monitoring and outcomes in phase 2 and 3 contemporary breast cancer clinical trials.

Methods Used

We searched Embase and Medline records for phase 2 and 3 breast cancer pharmacotherapy trials. We examined exclusion criterion due to CV conditions, adverse CV event reporting, and whether CV safety was assessed through CV imaging, electrocardiogram, troponin, or brain natriuretic peptide (BNP). Fischer’s exact test was applied for comparisons in reporting amongst trial characteristics.

Summary of Results

50 clinical trials were included in our study. Patients were excluded due to CV conditions in 42 (84%) trials. Heart failure was a frequent exclusion criterion (n=31; 62% trials). Adverse CV events were reported in 41 (82%) trials. CV safety assessments were not reported in 23 (46%) trials; while BNP and troponin assessments were not reported in any trial. CV safety assessments were more frequently reported in pharmaceutically funded trials (p<0.001), and in trials administering targeted/immunotherapy agents compared to only hormonal/traditional chemotherapy (p<0.001).

Conclusions

Our findings demonstrate significant under-representation of patients with CV conditions or prevalent CV disease in contemporary later phase breast cancer trials. Additionally, CV safety is not routinely monitored in these trials. Therefore, contemporary breast cancer clinical trials may possibly underestimate the CV risks of cancer pharmacotherapy agents for use in clinical practice.

191 Incidence of acute myocardial infarction and hurricane katrina: fourteen years after the storm

D Harrison1*

H Rawal1

M Quan1

A Ayoub1

D Sangani1

M La1

M Kogan1

R Subedi1

AK Irimpen1,2

S Srivastav1

A Johnson1

1Tulane Medical Center, Tulane Medical Center, New Orleans, LA, US, New Orleans, LA

2Veterans Administration, New Orleans, LA

Purpose of Study

We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the fourteen years since Hurricane Katrina

Methods Used

This was a single-center retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years before Hurricane Katrina and fourteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data

Summary of Results

In the fourteen-year post-Katrina period, there were 3469 admissions for AMI out of a total census of 114,795 (3.0%) compared to 150 admissions out of a census of 21,079 (0.7%) in the 2-year, pre-Katrina group (p<0.001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (45.9% vs. 30.7%, p<0.001), diabetes mellitus (40.6% vs. 28.7%, p=0.002), hypertension (80.3% vs. 74.0%, p=0.028), hyperlipidemia (56.7% vs. 44.7%, p=0.001), smoking (54.0% vs. 39.3%, p<0.001), drug abuse (18.2% vs. 6.7%, p<0.001), and psychiatric disease (15.6% vs. 6.7%, p<0.001). The post-Katrina group was more often prescribed aspirin (50.1% vs. 31.3%, p<0.001), beta-blocker (47.3% vs. 34.0%, p=0.002), ACE inhibitor or ARB (52.5% vs. 36.0%, p<0.001), and statin (52.8% vs. 28.0%, p<0.001) but with higher medication non-adherence (15.9% vs. 7.3%, p<0.001). The post-Katrina patients were more likely to be unemployed (41.3% vs 22.7%, p<0.001) and non-married (56.3% vs. 52.7%, p<0.001). Rates of STEMI were lower in the post-Katrina group (28.8% vs 42.0%, p=0.001). There was no significant difference between the two groups in terms of sex, being uninsured, or prior coronary artery bypass grafting

Conclusions

There was a 4-fold increase in the incidence of AMI fourteen years following Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post-Katrina group. These findings add to the growing body of literature demonstrating adverse cardiovascular outcomes after a natural disaster. Further research is needed to elucidate underlying mechanisms to help mitigate future cardiac morbidity

192 Prevalence of abnormal spect myocardial perfusion imaging during the COVID-19 pandemic

UA Hasnie*

P Bhambhvani

A Iskandrian

FG Hage

University of Alabama at Birmingham, Birmingham, AL

Purpose of Study

There has been a decline in the rate of abnormal MPI studies reported over several decades. The COVID-19 pandemic resulted in restrictions that reduced the volume of cardiovascular procedures and imaging. It is not clear if the restriction on performing MPIs caused by the pandemic impacted the rate of abnormal MPI studies.

The aim of this study is to evaluate the rate of abnormal myocardial perfusion imaging (MPI) studies at a single medical center during the COVID-19 pandemic compared to its rate prior to the pandemic.

Methods Used

We retrospectively studied MPI studies performed during the peak of COVID-19 restrictions at the University of Alabama Medical Center in comparison to the same time period in 2019.

Summary of Results

The MPI volume was reduced from 553 per month in 2019 to 105 per month in 2020 (i.e. to 19% of pre-pandemic utilization). The proportion of abnormal MPI for the 2020 cohort (61±13 years, 48% men, 41% black) was not different from the 2019 cohort (62±12 years, 48% men, 42% black) (31% vs. 27%, p=0.4). Similar proportion of patients in the 2 cohorts had abnormal myocardial perfusion, moderate-large perfusion defects, myocardial ischemia, myocardial scar, and abnormal left ventricular ejection fraction. The proportion of MPIs that were abnormal was not different based on whether patients were evaluated face-to-face or by tele-medicine (28% vs. 27%, p>0.9) but was higher for cardiology providers (40% vs. 20%, p<0.001).

Conclusions

There was a significant reduction in the number of MPI studies performed during the peak restrictions from the pandemic. Despite this restriction, the rate of abnormal studies remained stable. Our study suggests that it remains difficult to predict which patients will have abnormal MPI even when providers and stress laboratories are forced to prioritize the performance of studies to high-yield patients.

193 Hyperaldosteronism secondary to renin-angiotensin-aldosterone system activation in heart failure

A Jain1*

EW Reynolds2

S Jain1

1The University of Texas Medical Branch at Galveston, Galveston, TX

2The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX

Purpose of Study

Congenital heart defects can lead to heart failure (HF). HF decreases renal perfusion resulting in activation of the renin-angiotensin-aldosterone system (RAAS) leading to hyperaldosteronism. This leads to sodium (Na) and water retention and urinary potassium (K) loss, evident by low urinary Na:K ratio. Chronic use of furosemide also activates the RAAS and sympathetic nervous system with persistent hyperaldosteronism leading to a poor prognosis. The objective of this study is to investigate RAAS activation in HF by measuring serum aldosterone and renin and urine Na and K levels before and after medical treatment.

Methods Used

This is an observational study of infants with VSD who developed HF requiring treatment with furosemide and captopril. Infants with lethal anomalies were excluded. Blood and urine were collected before initiation and 2 weeks after starting treatment. Serum aldosterone, renin, and NT-proBNP along with urine Na and K were measured.

Summary of Results

This is an interim analysis of the first 5 patients. The mean gestational age was 35.3 ±3.3 weeks and mean birth weight of 2768 ±916 g. Mean pretreatment NT-proBNP was 10532 ±10177 pg/mL (normal <125 pg/mL), renin 58 ±40 ng/mL/hr (normal 2–35 ng/mL/hr), aldosterone 232 ±201 ng/dL (normal <16 ng/dL), urine Na 6.2 ±1.6 mmol/L (normal >20 mmol/L), and urine K 68.6 ±44.8 mmol/L (normal 5–10 mmol/L). Mean posttreatment BNP was 6500 ± 2718 pg/mL, renin 58 ±15 mg/mL/hr, aldosterone 182 ±138 ng/dL, urine Na 12.4 ±9.4 mmol/L, and urine K 27.7 ±15.3 mmol/L.

Abstract 193 Table 1

RAAS Activation

Conclusions

Our study demonstrates that HF leads to persistent hyperaldosteronism secondary to RAAS activation despite 2 weeks of medical treatment. This pilot data can be used to guide a multicenter study to further investigate the role of RAAS activation in HF.

194 Effects of sex and race on guideline directed medical therapy for heart failure with reduced ejection fraction

S Kancharla*

AA Oshunbade

RC Long

G Hernandez

B Lennep

L Papadimitriou

C Moore

J Butler

ME Hall

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

Recent evidence from the Change the Management of Patients with Heart Failure (CHAMP-HF) registry suggests there are opportunities for initiation/optimization of guideline directed medical therapies (GDMT) including beta blockers (BBs); angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or angiotensin receptor neprilysin inhibitors (ARNIs); and mineralocorticoid antagonists (MRAs) in patients with heart failure with reduced ejection fraction (HFrEF). We examined HF GDMT prescription patterns in a large, tertiary-care medical center to determine whether sex and race affect prescription of these important medications.

Methods Used

This analysis included data from 10,812 adult patients with HFrEF from 2013–2019 from the University of Mississippi Medical Center. All data was extracted from the electronic medical record Patient Cohort Explorer. We examined prescription patterns of GDMT for HFrEF patients by sex and race, including ACEIs/ARBs, ARNIs, HF BBs, and MRAs.

Summary of Results

Among included HFrEF patients, 41.3% were women and 59.6% were black. These patients were insured primarily by Medicare/Medicaid (62.2%) and private insurance (13.8%), while 21.8% had no insurance coverage. Overall, we found suboptimal rates of HF GDMT prescriptions: 53.2% on ACEIs/ARBs, 9.6% on ARNIs, 62.2% on BBs, and 24.8% on MRAs. We noted higher percentages of black patients with HFrEF were on BBs (66%) and MRAs (28%) in comparison to white patients with HFrEF (56.7% and 20.2%, respectively). Men with HFrEF had higher prescription rates of HF GDMT. This difference was most pronounced with BB prescriptions – 64.3% in men versus 59.2% in women.

Conclusions

Our institution appears to have significant opportunities for initiation of Class I indicated GDMT for HFrEF. Despite some differences noted with regard to sex and race, the overall prescription rates are lower than 70%. Suboptimal prescriptions rates were especially pronounced with ARNIs and MRAs. While some patients could have contraindications to some of these therapies, there is likely a large proportion without contraindications not on GDMT for HFrEF.

195 Predictors for 30-day readmission for recurrent syncope

S Khan*

R Kamoga

D Nair

N Mehta

White River Medical Center, Batesville, AR

Purpose of Study

Syncope is a common medical problem with 18.1–39.7 episodes per 1000 patients.1 Prior analyses have estimated the 30-day readmission to be at 9.3%.2 The causes and predictors for recurrent syncope readmission are unclear. Since recurrent syncope is the most common cause of readmission, we sought to determine the factors that predict these readmissions.

Methods Used

We utilized the Nationwide Readmission Database to identify admissions with a principal diagnosis of Syncope (ICD-9 780.2). Applicable admissions were all adults (age ≥ 18) from January 1 to November 30, 2014. All-causes including syncope readmissions (either as principal or secondary diagnosis) within 30-days of an index syncope admission were analyzed. Readmission predictors were determined using a multivariate logistic regression model following sequential step-wise elimination of covariates.

Summary of Results

A total of 63,282 patients were admitted for syncope. There were 6,320 readmissions (9.99%) within 30-days of index admission. Of readmissions, 17.53% were readmitted for recurrent syncope. The Length Of Stay (LOS) for those readmitted was 2.97 days (Confidence Interval, CI 2.81–3.13) while those not readmitted was 2.67 days (CI 2.65–2.69) which was statistically significant (p<0.001). The statistically significant predictors of recurrent syncope readmission were leaving Against Medical Advice (Odds Ratio [OR] 2.11, 95% CI 1.63–2.76), discharge to short term hospital (OR 3.75, CI 2.49–5.64), Age 18–35 (OR 1.89, CI 1.33–2.68), metropolitan (> 1 mill.) hospitals (OR 0.75, CI 0.63–0.90), female gender (OR 0.85, CI 0.75–0.96) and private payers (OR 0.78, CI 0.63–0.97). Income quartile and the presence of comorbidities such as obesity or Chronic Kidney Disease (CKD) did not influence readmission.

Conclusions

While syncope has a 10% 30-day readmission rate, 1/6 patients will be readmitted for recurrent syncope. Provider awareness of predictors of recurrent syncope may allow for the development of interventions to decrease the rate of readmissions.

196 The rapid evolution of invasive strategies for the management of pulmonary embolism to-date

M Maturana1*

M Seitz2

I Pour-Ghaz3

UN Ibebuogu3

RN Khouzam3

1The University of Tennessee Health Science Center College of Medicine, Memphis, TN

2Lenox Hill Hospital, New York, NY

3The University of Tennessee Health Science Center, Memphis, TN

Purpose of Study

This abstract aims to outline the current major interventional treatments for pulmonary embolism through 2020.

Methods Used

We conducted a Medline search of ‘interventional pulmonary embolism treatment’ to identify pivotal trials published before May 15, 2020 for this review of the latest modalities for treatment of pulmonary embolism (PE).

Summary of Results

While the cornerstone of treatment for PE is anticoagulation, more aggressive therapies are increasingly being developed and used to treat high-risk PEs, including systemic thrombolysis, catheter-directed thrombolysis (CDL), ultrasound-assisted thrombolysis (USAT) and mechanical thrombectomy (MT). Systemic thrombolysis is effective but has increased risk of major bleeding. Conversely, CDL, USAT, and MT use alternative devices for treating for high-risk PEs. CDL and USAT involve catheter-directed injection of a thrombolytic drug, and MT uses catheter-directed aspiration of thrombus. Our study provides an in-depth overview of all devices in use, their research trials, and each device’s indications, advantages, and disadvantages.

Conclusions

Interventional devices have shown promising results in treatment of high-risk PE’s. In particular, the EXTRACT-PE trial and subsequent FDA approval of the Indigo Thrombectomy System is a major recent development. Its small size, ease of delivery to pulmonary arteries and low adverse event rate make it arguably the best overall device to date. However, clinical trials for catheter-based devices so far have been limited to mostly single-arm studies measuring short-term surrogate outcomes. These studies offer a preliminary evaluation of the safety and efficacy of devices but are not sufficient to stratify risk and guide clinical practice. Large RCTs are needed to fully examine these risks and long-term outcomes and to create a more clear and specific set of guidelines for use of these devices.

197 Machine learning-based prediction of positive-culture sepsis after the norwood operation in children with single ventricle lesions

AG Moreira1,2*

K Chorath3

A Moreira4

1Texas Children’s Hospital, Houston, TX

2Baylor College of Medicine, Houston, TX

3The University of Pennsylvania, Philadelphia, PA

4The University of Texas Health Science Center at San Antonio, San Antonio, TX

Purpose of Study

The Norwood operation for single ventricle lesions is one of the most complex congenital heart surgeries with a mortality of 22% postoperatively, and 75% of children having at least 1 post-operative complication. Acquiring sepsis after the Norwood operation increases mortality by 13%. The aim of this study was to examine the performance of machine learning approaches to predict positive-culture sepsis in children with a single ventricle lesion.

Methods Used

A secondary data analysis of children from the Pediatric Heart Network Single Ventricle Reconstruction Trial. A total of 549 individuals from multiple cardiac intensive care units around the country were included. The outcome was culture-proven sepsis evaluated between the Norwood and Glenn procedure. In the training set (70% random sample), using demographic, clinical, and surgical predictors, we derived three machine learning models: logistic regression, extreme gradient-boosted decision tree, and k-nearest neighbors. We measured the models’ prediction performance by computing C statistics in the remaining test set (30% random sample).

Summary of Results

Fourteen percent (n=78) of children were diagnosed with sepsis [mean (SD) gestational age, 38.1 (1.6) weeks; 61.9% male; mean (SD) age at Norwood, 6.8 (4.1) days]. Extreme gradient-boosted decision tree had the best C-statistic for predicting sepsis at 81.6% (CI 0.718 - 0.914). Logistic regression and k-nearest neighbors had a C-statistic of 59.1% and 74.0%, respectively. Age at discharge was the top predictor followed by echocardiographic measures of right ventricular function, intraoperative variables, and demographic features.

Conclusions

Machine learning-based predictors can help clinicians determine which children with single ventricle lesions are at highest risk of developing sepsis after the Norwood operation.

198 Increased covid-19 mortality in American Indians and those with prevalent atherosclerotic cardiovascular disease

H Nannapaneni*

A Oshunbade

ME Hall

MR McMullan

University of Mississippi Medical Center, Jackson, MS

Purpose of Study

The coronavirus disease-2019 (COVID-19) pandemic has been associated with varying mortality. Racial disparities and underlying medical conditions appear to play a role.

Methods Used

We retrospectively analyzed data from a large academic medical center in Mississippi using the electronic health record Patient Cohort Explorer. We evaluated differences in mortality rates among racial groups, between sexes, and based on a diagnosis of prevalent atherosclerotic cardiovascular disease (ASCVD). Multivariable regression models were performed to assess the differences and odds of dying due to COVID-19 by race and ASCVD status.

Summary of Results

Among 804 adults aged ≥19 years admitted to the University of Mississippi Medical Center with COVID-19 from 3/14/2020 to 9/14/2020, 521 (65%) were Black, 153 (19.1%) were White and 54 (6.7%) were American Indian or Alaska Native (AI), and 151 (19.8%) patients had ASCVD. In patients without ASCVD, mortality rates were similar between Black and White patients (13.2 vs 15.1%, respectively), but were higher in AIs (37.8%). Mortality rates were also similar between Black and White patients with ASCVD (33.7 and 37.8%, respectively) but higher in AIs with ASCVD (55.6%). Patients with ASCVD had higher mortality rates compared to those without ASCVD (36.4 vs 14.9%, respectively). After adjustment for age and sex, the odds of dying was significantly higher among AIs (OR 4.93 p<0.001). ASCVD was also associated with increased likelihood of mortality in patients with COVID-19 (OR 3.36 p<0.001), irrespective of race.

Conclusions

In a large academic medical center, AIs had about 5-fold increased risk of dying from COVID-19 and a diagnosis of ASCVD also presaged increased mortality in patients with COVID-19. Based on our findings, physicians should have a heightened awareness of risk of dying from COVID-19 in AIs and those with underlying ASCVD.

199 Evaluation of glucose tolerance test in guanylyl cyclase/natriuretic peptide receptor-a gene-targeted mutant mice

K Neelamegam*

C Ramasamy

KN Pandey

Tulane University School of Medicine, New Orleans, LA

Purpose of Study

Atrial natriuretic peptide (ANP) acting through the guanylyl cyclase/natriuretic peptide receptor-A (GC-A/NPRA), plays pivotal roles in the regulation of blood pressure and cardiac homeostasis. The disruption of the Npr1 (encoding GC-A/NPRA) in mice exhibits hypertension and provokes renal and congestive heart failure; however, the underlying mechanisms are not yet precisely determined. The objective of present study was to investigate whether Npr1 gene plays a critical role in regulating glucose homeostasis in Npr1 gene-disrupted haplotype and gene-duplicated mice.

Methods Used

The adult male (14–18 wks) Npr1 gene-knockout haplotype (Npr1±, 1-copy), wild-type (Npr1+/+, 2-copy), and gene-duplicated (Npr1+ +/+ +, 4-copy) mice were fasted overnight (16 h) and given free access to water. The mice were administrated with glucose both orally and intraperitoneally (2 g/kg body weight) to determine oral glucose tolerance test (OGTT) and intraperitoneal glucose tolerance test (IPGTT). Blood glucose levels were determined by performing tail bleeds at 0, 15, 30, 60, 90, and 120 min using the AlphaTRAK blood glucose monitoring system.

Summary of Results

The results showed that administration of glucose resulted in a greater increase in blood glucose levels at 120 mins in 1-copy mice (OGTT: 237 ± 5 mg/dL, IPGT: 246 ± 6 mg/dL) than 2-copy male (OGTT: 131 ± 3 mg/dL, IPGT: 126 ± 6 mg/dL), respectively. The blood glucose was also significantly lower in 4-copy mice (OGTT: 113 ± 5 mg/dL, IPGT: 108 ± 7 mg/dL) compared with 2-copy mice. Systolic blood pressure (SBP) was determined by non-invasive tail-cuff method (Visitech 2000). SBP was significantly greater in 1-copy mice (130 ± 4 mmHg) than 2-copy mice (100 ± 3 mmHg). Similarly, SBP was also significantly lower in 4-copy mice (90 ± 2) than 2-copy mice. The increase in plasma glucose levels were significantly lower in OGTT than IPGTT.

Conclusions

These results revealed that Npr1 gene markedly prevented a steep rise of blood glucose levels after glucose challenge and ameliorated glucose intolerance in wild-type 2-copy and gene-duplicated 4-copy mice than haplotype 1-copy mice, suggesting that glucose homeostasis might be regulated by Npr1 gene.

200 Race is not a predictor of major cardiovascular events or mortality in COVID-19 patients

H Nguyen*

F Ikram

N Nguyen

C Patel

P Acharya

A Dhillon

M Sidhu

Methodist Health System, Dallas, TX

Purpose of Study

To determine if race is linked with higher rates of MACE and/or mortality in patients hospitalized for COVID-19.

Methods Used

Our retrospective observation cohort study analyzed 496 hospitalized patients to determine if race was a predictor for poorer outcomes (MACE or death). Data was obtained from review of the electronic medical records of de-identified patients that tested positive for COVID-19. Statistical analysis using Pearson’s chi square test was used to compare race with incidence of MACE or death.

Summary of Results

Out of the 484 patients that had data available on race, 132 (37.39%) were Black or African American, 87 (24.65%) were white or Caucasian and 134 (37.96%) were other ethnicities. No significant association was observed between race and higher risk for MACE or death in COVID-19 patients (p-value = 0.878).

Conclusions

While African Americans make up a larger demographic of hospitalized COVID-19 patients, they are just as likely as any other race to have MACE or death. Our study shows that race does not affect the rate of MACE or death.

201 Elevated body mass index is not associated with incidence of major adverse cardiovascular events or death in covid-19 patients

H Nguyen*

F Ikram

N Nguyen

C Patel

P Acharya

A Dhillon

M Sidhu

Methodist Health System, Dallas, TX

Purpose of Study

To determine if elevated BMI is associated with higher rates of major adverse cardiovascular events (MACE) and/or mortality in patients hospitalized for COVID-19.

Methods Used

Our retrospective observation cohort study analyzed 496 hospitalized COVID-19 patients to determine if elevated BMI is associated with MACE and/or mortality. Data was obtained from review of the electronic medical records of hospitalized COVID-19 patients. A two-sample Wilcoxon rank-sum (Mann-Whitney test) was used to compare BMI to worse outcomes. The Fisher’s exact test was used to compare the BMI categories with worse outcomes. MACE was defined as a composite of myocardial infarction, deep venous thrombosis pulmonary embolism, stroke or shock requiring vasopressor support. BMI categories were as follows: Underweight (BMI<18.5), Normal (BMI 18.5 to <25), Overweight (BMI 25 to <30), and Obese (BMI>30).

Summary of Results

Of the 495 patients with BMI data available, 358 (72%) did not have MACE or death and 137 (28%) had MACE or death (p = 0.5126). Examination of outcomes based on BMI category found that 0.56% of underweight patients did not have MACE or mortality versus 2.19% with worse outcomes, 19.55% of normal BMI patients did not have worse outcomes versus 21.17% with MACE or mortality. 32.68% of overweight patients did not have worse outcomes versus 29.93% with worse outcomes, and 47.21% of obese patients did not have worse outcomes versus 46.72% with worse outcomes (p = 0.392).

Conclusions

Our study shows that obese patients were not as likely to develop MACE or death compared to patients with normal or low BMIs. Furthermore, patients in higher BMI categories were not as likely to experience MACE compared to those in lower BMI categories. In conclusion, the incidence of MACE and mortality in COVID-19 positive patients is independent of obesity and BMI.

202 Hypertensive diseases in pregnancy and kidney function later in life

AA Oshunbade1*

ST Lirette1

B Windham1

T Shafi2

A Hamid1

S Gbadamosi3

W Yimer1

D Clark1

D Kamimura1

R Mentz4

ER Fox1

J Butler1

K Butler1

V Garovic5

S Turner5

T Mosley1

ME Hall1

1University of Mississippi Medical Center, Jackson, MS

2University of Mississippi Medical Center, University of Mississippi Medical Center, Jackson, MS

3Florida International University, Miami, FL

4Duke University, Durham, NC

5Mayo Clinic Minnesota, Rochester, MN

Purpose of Study

Hypertension in pregnancy has been associated with increased risk for end-stage kidney disease; however, there are limited data assessing the relationship between hypertensive diseases in pregnancy and kidney function later in life.

Methods Used

We evaluated kidney function in 725 women of the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Women were classified by self-report as nulliparous (n=62), a history of normotensive pregnancies (n=544), a history of hypertensive pregnancies (n=102), or a history of preeclampsia (n= 17). We compared adjusted associations among these 4 groups with measured (iothalamate clearance) and estimated (Cystatin C) GFR measurements of kidney function using generalized estimating equations to account for familial clustering.

Summary of Results

Among women with renal function measurements (mean age 59 ± 9 years, 53% African American). Those with a history of hypertensive pregnancy had lower GFR (iothalamate urinary clearance: β-coefficient,-4.66 ml/min/1.73 m2, 95% CI -9.12, -0.20) compared to women with a history of normotensive pregnancies. Compared to women with a history of normotensive pregnancies, women with a history of hypertensive pregnancy had higher odds of GFR < 60 ml/min/1.73 m2 by iothalamate urinary clearance (OR 2.09, 95% CI 1.21,3.60). Additionally, women with a history of hypertensive pregnancy had greater odds for chronic kidney disease (OR 4.89, 95% CI 1.55, 15.44), after adjusting for risk factors.

Conclusions

A history of hypertension in pregnancy is an important prognostic risk factor for kidney disease several years later.

203 Smoke and heart should stay apart: e cigarettes and other alternatives to conventional cigarettes’ impact on cardiovascular health

J Raja*

A Khouzam

N Khouzam

R Khouzam

UTHSC, Memphis, TN

Purpose of Study

This abstract aims to review alternatives to conventional cigarettes, and their impact on cardiovascular health.

Methods Used

We conducted a Medline search of ‘E cigarettes,’ ‘Smokeless tobacco,’ ‘hookah’, and ‘cardiovascular risk’ to identify pivotal trials published before May 10, 2020, for inclusion in this review. Major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. The following section reviews data from pivotal trials to review the effects of E cigarettes, smokeless tobacco, hookah, nicotine replacement therapy on cardiovascular health.

Summary of Results

E cigarettes are associated with increased risk of atherosclerosis leading to myocardial infarction, stroke as well as arrhytmogenic property of the cigarettes have been noted. E cigarettes also lead to vaping associated illness which can culminate into acute respiratory distress syndrome. Hookah use leads to increased smoke inhalation even compared to cigarettes. Evidence points towards higher risk of CAD among hookah users. Though initial evidence for smokeless tobacco products like ‘snuff’, ‘snus’, or chewable tobacco did not show any association, recent and emerging research shows increased in MI and cardiovascular mortality. The only cigarette alternative that remains safe from a cardiovascular perspective are nicotine Replacement therapy.

Abstract 203 Table 1

Cardiovascular impact by conventional tobacco cigarettes alternative.

Conclusions

The abundance of evidence regarding alternatives to conventional cigarette’s impact on cardiovascular mortality and morbidity does not position it as a safe alternative, but an alternative means of smoking nicotine. The humongous rise in popularity and its gain in favor among the younger population poses a serious threat to the cardiovascular well- being of the exposed. Thus, E cigs and other alternatives of cigarette smoking do impart differing risks in cardiovascular mortality and morbidity, with the possible exception of nicotine replacement therapy.

204 The prevalence of pathologic q waves in pediatric patients with confirmed hypertrophic cardiomyopathy: a systemic review of the literature

K Singhapakdi*

L Mellick

University of South Alabama, Mobile, AL

Purpose of Study

The electrocardiogram (ECG) of patients with hypertrophic cardiomyopathy (HCM) ranges from normal to exhibiting evidence of ventricular hypertrophy, a classic finding being deep Q waves in the inferior and lateral leads. However the prevalence of this finding in pediatric HCM patients is not well-established. The purpose of this review is to describe the prevalence of pathologic Q waves in pediatric patients with echocardiogram proven HCM.

Methods Used

PubMed, Web of Science, Scopus and CINAHL were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. The Rayyan Systemic Review Software was used to screen for final review. The initial search (Search 1) consisted of the following terms: ‘dagger Q wave’, ‘dagger-like Q waves’, ‘dagger shape Q waves’, ‘deep Q wave’ ‘narrow Q wave’, ‘Q wave elevation’ and ‘hypertrophic cardiomyopathy’. A broader search (Search 2) was conducted using the same terms except ‘hypertrophic cardiomyopathy’. The authors then reviewed the articles these searches yielded as well as the references of the articles.

Summary of Results

This yielded 9 articles that specifically addressed the prevalence of pathological Q waves in pediatric HCM patients. The articles described a total of 845 pediatric patients with hypertrophic cardiomyopathy. Of these, 258 (30.5%) demonstrated pathological Q waves on their electrocardiograms. The range of percentages reported for pathological Q waves was 12.5–66.7%.

Conclusions

Our systematic review confirmed that pathologic Q waves are a common and early finding in children with HCM and may sometimes be the only ECG finding.

205 Incidence of major adverse cardiovascular events in covid-19 infected patients at a major southwest metropolitan quaternary care hospital

CD Ukoha*

M Sidhu

FG Ikram

C Patel

N Nguyen

H Nguyen

L Hoang

P Acharya

Methodist Dallas Medical Center, Dallas, TX

Purpose of Study

The world reached over eight million cases of COVID-19 in June 2020. There are several unknown cardiovascular manifestations of COVID-19, specifically major adverse cardiovascular events (MACE). The purpose of this study is to identify the incidence of MACE within the COVID-19 infected patient population hospitalized in a major Southwest metropolitan quaternary care hospital.

Methods Used

A total of 496 patients tested positive for COVID-19 from March 2020 to June 2020 at a major Southwest metropolitan quaternary care hospital. Electronic medical records of these cases were reviewed to identify any evidence of MACE. MACE was defined as a composite of myocardial infarction, stroke, deep venous thrombosis/pulmonary embolism or shock requiring vasopressor support.

Summary of Results

In this single-center retrospective study, all 496 patients who tested positive for COVID-19 and were hospitalized were included. The mean age of the patients was 58.2 (SD=14.5) years, with 39% of the patients between 40 and 60 years of age. More than 70% of the patients were African American or a race other than White. Overall, 122 of the 496 patients developed a MACE during hospitalization. 493 patients had at least one of the following comorbidities: hypertension, diabetes, chronic obstructive pulmonary disease (COPD), asthma, or obesity (BMI>30). 82 patients had hypertension, 20 patients had COPD or asthma, and 59 patients had a BMI greater than 30. Of the 122 patients who developed a MACE, 83.2% did not have COPD or asthma. Forty-nine (40.1%) of the COVID-19 infected patients had a MACE or expired during hospitalization.

Conclusions

This study revealed that a substantial percentage of COVID-19 patients developed a MACE during admission, and most of these patients did not have an underlying lung condition including COPD or asthma. Despite studies indicating a higher risk of complications in obese patients with COVID-19, only half of the COVID-19 population with MACE had a BMI >30.

206 Angiotensin II type 2 receptor regulates skeletal muscle stem (satellite) cell differentiation and potentiates muscle regenerative capacity via GSK-3β/β-catenin pathway: implications for treatment of cachexia and skeletal muscle wasting

T Yoshida*

P Delafontaine

Tulane University, New Orleans, MO

Purpose of Study

Patients with advanced congestive heart failure (CHF) or chronic kidney disease (CKD) often have increased angiotensin II (Ang II) levels and cachexia. We previously demonstrated that Ang II type 2 receptor (AT2R) potentiates skeletal muscle stem (satellite) cell (SC) differentiation. However, AT2R expression is suppressed in Ang II-mediated muscle atrophy, suggesting the involvement of AT2R signaling. We aimed to identify the downstream signaling of AT2R in SCs, and to assess its role in skeletal muscle regeneration and atrophy.

Methods Used

AT2R downstream signaling pathways were analyzed in AT2R knockdown cells by phosphoprotein array. The identified signaling pathway was pharmacologically and genetically manipulated both in vitro and in vivo, and the skeletal muscle regenerative capacity was analyzed by qRT-PCR, western blotting and immunohistochemistry. Also, AT2R-overexpressing transgenic animal was generated and the changes in SC signaling was analyzed.

Summary of Results

We found that 20 phosphoproteins were upregulated (>1.4 fold change) and 28 were downregulated (<0.7 fold change) in SCs after AT2R knockdown. The analysis indicated an involvement of Akt/GSK-3β/β-catenin pathway, and β-catenin TCF/LEF reporter (TOPFlash) assay showed an increase in β-catenin activity both in vitro and in vivo during SC differentiation. AT2R knockdown in cultured SCs significantly inhibited Akt/GSK-3β/β-catenin pathway, and importantly, decreased SC differentiation. In transgenic mice that overexpress AT2R specifically in SCs, muscle regeneration is potentiated in association with increased Akt/GSK-3β/β-catenin pathway. Furthermore, pharmacological activation of Akt/GSK-3β/β-catenin pathway restored SC regenerative capacity both in vitro and in vivo after AT2R knockdown. Importantly, Ang II-induced decline in muscle regenerative capacity and muscle atrophy development were both prevented by AT2R overexpression and activation of Akt/GSK-3β/β-catenin pathway in vivo.

Conclusions

These data indicate that AT2R/Akt/GSK-3β/β-catenin pathway plays a critical role in regulating SC differentiation and muscle regeneration, and could be a novel therapeutic target in wasting disorders such as CHF and CKD.

207 Paradoxical hypotension and pulmonary edema after surgical pericardiotomy for cardiac tamponade: an under-reported complication to anticipate

J Abdelmalek*

M Abohelwa

M Elmassry

E Elgwairi

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Pericardial decompression syndrome (PDS) is a rare and serious complication that ensues after often-initially-uncomplicated pericardial drainage in patients with pericardial effusion and tamponade physiology.

Here we report a case of PDS in a 70-year-old male with end stage renal disease (ESRD) who underwent surgical pericardial window for drainage of a moderate pericardial effusion with tamponade physiology. After presenting with severe dyspnea, hypoxia and hypotension, his vital signs initially improved after drainage of pericardial fluid.

Few hours after surgery patient developed pulmonary edema and hemodynamic instability requiring intubation, mechanical ventilation and vasopressor support.

Compared to his normal Echocardiogram 2 months prior to this hospitalization, an Echocardiogram done in the ICU postoperatively showed moderately reduced left ventricular ejection fraction 30–34%, with apical, lateral and inferior wall hypokinesis, significant right ventricular systolic dysfunction, and paradoxical ventricular septal wall motion.

EKG showed no acute ischemic changes, cardiac biomarkers were only mildly elevated in the setting of ESRD.

A diagnosis of pericardial decompression syndrome was made.

Vasopressors were weaned gradually over a duration of 5 days, patient was extubated, his fluid status improved with continuous renal replacement therapy, he was transferred to the stepdown unit and later discharged 13 days after admission.

A follow-up Echocardiogram 6 months after discharge showed normalization of his left ventricular systolic function with ejection fraction estimated at 50–54%.

This case provides further evidence that rapid pericardial decompression, notably with pericardiotomy, can lead to acute life-threatening low cardiac output heart failure, particularly in patients with underlying cardiac risk factors. Early recognition, diagnosis and supportive treatment in the intensive care unit is crucial for improving survival.

208 A case of pembrolizumab induced complete heart block

M Abohelwa1*

M Elmassry1

M Ali Hassan2

E Elgwairi1

J Abdelmalek1

K Nugent1

1Texas Tech University Health Sciences Center, Lubbock, TX

2American University of Beirut, Beirut, Lebanon

Case Report

Introduction

Pembrolizumab is a monoclonal antibody directed towards programmed cell death protein 1 (PD-1).It is commonly used in the treatment of non-small cell lung cancer. It’s associated with multiple immune-related side effects. Here, we present a case of complete heart block (CHB) 14 days after pembrolizumab administration.

Case Presentation

A 57-year-old female patient known to have metastatic non-small cell lung cancer presented with syncope. She was started on treatment for non-small cell lung cancer nine months before the presentation to the ED. Initially, she received induction with cisplatin and pemetrexed, then pemetrexed as maintenance therapy with a good partial response. However, her disease progressed. Only three percent of the patient’s tumor cells expressed PDL-1. Therefore, the patient was started on pembrolizumab 14 days before her presentation. Upon presentation to the ED, her electrocardiogram (EKG) showed a CHB. Her previous EKG was normal sinus. The troponin level was trended, and it was normal. A temporary pacemaker was inserted. Coronary angiography was done, and it showed normal coronary vessels. The patient was started on high dose corticosteroids. However, after seven days, she was still in CHB. Therefore, a permanent pacemaker was inserted.

Discussion

Pembrolizumab immune-related side effects have commonly been reported in the literature e.g., thyroiditis, hepatitis, hypophysitis, pneumonitis, etc. Although it is rare, cardiovascular complications have been reported as a side effect of pembrolizumab therapy. It might cause arrhythmias, pericarditis, myocarditis, pericardial effusion, and tamponade. CHB is a rare complication following pembrolizumab therapy. Various proposed mechanisms have attempted to explain immune checkpoint inhibitor-mediated arrhythmias. Some of these theories include ventricular myocarditis with inflammation and fibrosis or inflammation of the His-Purkinje conduction system, leading to re-entry arrhythmia. Atrial or ventricular arrhythmias secondary to inflammation without myocarditis and atrial and ventricular arrhythmias from functional cardiotoxicity without inflammation are other possibilities.

209 Concurrent acute corianry syndrome and acue infection: a case report

M Abohelwa1*

A Gharamti2

M Elmassry1

J Abdelmalek1

TE Whisenant1

P Sethi1

1Texas Tech University Health Science Center, Lubbock, TX

2American University of Beirut, Beirut, Lebanon

Case Report

Introduction

An increase in the short- and long-term risk of myocardial infarction (MI) in the setting of acute infections is well described in the literature. We present a case of concomitant acute MI and acute cholecystitis. The latter was diagnosed following the persistence of abdominal pain after successful stenting.

Case presentation

A 41-year-old man with hypertension and recently diagnosed Inflammatory Bowel Syndrome presented with severe epigastric pain radiating to the interscapular area of 3 hours duration, associated with diaphoresis, nausea, and vomiting. His vital signs were normal, except for a heart rate of 49. EKG showed sinus bradycardia and ST-segment elevation in leads II, III, and a-VF. He was rushed to the cardiac catheterization lab and was found to have an 80% lesion with a high thrombus burden in the proximal RCA. A stent was successfully placed. Following the procedure, he reported persistence of the abdominal pain. Murphey’s sign was positive. Repeat EKG showed resolution of the ST-segment elevations with no new changes. A gallbladder ultrasound showed acute calculous cholecystitis. Since the patient was on dual antiplatelet therapy, surgical management was not possible, and he was medically managed with antibiotics. He was given seven days of intravenous piperacillin-tazobactam, followed by seven days of oral amoxicillin-clavulanate. The patient was last seen three months following discharge, and he was doing well and pain-free.

Discussion

The patient presented with acute MI and cholecystitis. It is essential to stay vigilant of the association between acute infections and MI. This is thought to be related to the prothrombotic and procoagulant states triggered by infections, such as enhanced platelet activation. Additionally, atherosclerotic plaques contain inflammatory cells, which can get activated by circulating cytokines such as Tumor Necrosis Factor (TNF)-α, produced by infections. Finally, infections increase the metabolic demands of the body, though inflammation and fever. This can increase the heart rate, shorten the diastolic filling time, and compromise coronary perfusion.

210 Subtle pre-excitation a wolf in sheep’s clothing

N Albrecht*

UF COM, Jacksonville, FL

Case Report

17-year-old presented with palpitations and chest pain with otherwise normal physical exam. Work-up with 12 lead ECG and echocardiogram was normal apart from a finding of an anomalous origin of the right coronary artery (ARCA) from the left sinus. CT angiography revealed an ARCA with a 1.5 mm interatrial course between the descending aorta and the right ventricular outflow tract. A stress echo was unremarkable for ischemia however the patient complained of worsening symptoms and underwent surgical unroofing of the right coronary ostium. At follow up the patient continued to report sporadic palpitations followed by chest pain with sudden onset and termination. Follow-up ECGs showed manifest pre-excitation. A review of ECGs, stress tests and perioperative tracings showed subtle pre-excitation at all heart rates. An Electrophysiology Study revealed an accessory pathway mapped to the left lateral mitral annulus with a Shortest Pre-excited RR Interval during atrial fibrillation of 250 msec and inducible antidromic reentrant tachycardia that was successfully ablated. On follow up patient is asymptomatic with no evidence of pre-excitation.

In conclusion, we stress the importance of a good history to elicit symptomatology. Palpitations due to ischemia typically follow chest pain whereas chest pain following palpitations indicate an arrhythmogenic etiology. Subtle pre-excitation due to a far-left lateral pathway may be difficult to discern in patients with a robust AV node tone.

Abstract 210 Figure 1

12 lead ECG demonstrating a) subtle preexcitation b) obvious preexcitation e) post ablation

Abstract 210 Figure 2

MRI image demonstrating the anomalous origin of the right coronary artery from the left sinus

211 Mins: cardiac arrest during laparoscopic appendectomy

AA Ali*

J Ruiz-Morales

W Kogler

K Esmail

University of Florida College of Medicine – Jacksonville, Jacksonville, FL

Case Report

A 47-year-old male diagnosed with acute appendicitis was planned for laparoscopic appendectomy. Intraoperatively at the time of intra-abdominal insufflation, the patient had an asystolic cardiac arrest with return of spontaneous circulation after cardiopulmonary resuscitation with epinephrine. EKG revealed ST-segment elevation in leads I, aVL, V5-V6. Emergent left heart catherization revealed angiographically normal coronary arteries with possible high anterolateral and mid-inferior hypokinesis. Troponin T resulted at 0.55 (0.00–0.03 ng/ml). Echocardiogram revealed an ejection fraction of 50–55% with all segments contracting normally. The patient was admitted to the coronary care unit and underwent urgent appendectomy within twenty-four hours.

Laparoscopy requires intrabdominal insufflation which results in elevated intrabdominal pressure with consequent inferior vena cava and aortic compression thus affecting cardiac hemodynamics resulting in decreased cardiac output. The patient‘s intraoperative cardiac arrest was likely due to the rapid changes in cardiac hemodynamics essentially from under-perfusion.

Coronary angiography revealed angiographically normal coronary vessels with anterolateral and mid-inferior hypokinesis likely as a result of under-perfusion and stunning of the left circumflex during intrabdominal insufflation. The patient was admitted for management of myocardial injury after non-cardiac surgery (MINS).

MINS is a clinically and prognostically relevant diagnosis due to myocardial ischemia either from supply demand mismatch. Diagnosis requires the presence of elevated cardiac biomarkers within 30 days of non-cardiac surgery without symptoms or EKG changes. The prevalence of MINS can be as high as 8% and carries with it a significant increase in 30-day mortality. Patients with MINS has a greater risk for vascular complications, recurrent myocardial injury/infarction, congestive heart failure, and life-threatening arrhythmias.

Carbon dioxide insufflation during laparoscopic procedures directly affects cardiac hemodynamics and can result in bradycardia, hypotension and cardiac arrest. Patients with myocardial injury after non cardiac surgery should be risk stratified and closely followed as they are at increased risk of future cardiac events.

212 Case of spontaneous coronary artery dissection

Q Aziz*

JA Cavo

J Fanning

The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL

Introduction

Spontaneous Coronary Artery Dissection (SCAD) is a rare life-threatening condition that occurs due to separation of the coronary vessel layers leading to ischemia and chest pain. It is associated with connective tissue and rheumatological diseases. It is commonly seen in females and in younger population. SCAD commonly involves the left main coronary vessel.

Case

A 31-year-old female with medical history of primary biliary cholangitis and rheumatoid arthritis (RA) comes to the emergency room with intermittent retrosternal chest pain and palpitations that started one day ago. The pain is stabbing, non-radiating and lasts a few minutes. She denies radiation, diaphoresis, dyspnea, nausea and vomiting. She had similar pain 2 weeks ago, which resolved. Denies any tobacco, alcohol, or illicit drug use. She takes prednisone and ursodiol. Physical exam findings include stable vital signs, chronically ill appearance, jaundice, scleral icterus, normal cardiac exam, clear lungs, and pitting edema in lower extremities. ECG negative for ischemic changes. Troponin level is 265. ECHO shows normal wall motion and ejection fraction. Left heart catheterization is highly suspicious for SCAD. An optical coherence tomography (OCT) to confirm the diagnosis was unsuccessful due to severe vessel spasm. She is treated with beta-blocker, aspirin, statin, amlodipine, and nitroglycerin.

Discussion

In SCAD an intimal tear leads to an intramural hematoma which reduces lumen size and distal blood supply. It can lead to myocardial infarction, arrhythmias and sudden death. Coronary angiography shows long and diffuse narrowing due to intramural hematoma. It is recommended to confirm diagnosis with OCT, intravascular ultrasound, or cardiac magnetic resonance imaging. Workup includes assessing for underlying inflammatory or autoimmune conditions, connective tissue disorders, hormone levels and fibromuscular dysplasia. Most common associations are RA, systemic lupus erythematosus, Crohn’s disease, Marfan syndrome, and Ehlers-Danlos syndrome. Management includes aspirin, beta blockers, clopidogrel, statin and treatment of underlying associated condition. If patient is hemodynamically unstable or has ischemic symptoms, percutaneous intervention or coronary artery bypass graft are considered.

213 The classic octopus trap

AD Brown*

D Busby

A Hamid

B Deere

University of Mississippi Medical Center, Canton, MS

Case Report

A 68-year-old female with end-stage renal disease and hypertension presented with a middle cerebral artery stroke. Two weeks prior, she had both a normal transthoracic echocardiogram (TTE) and coronary angiography. On arrival, she was hypotensive with low voltage on electrocardiogram (ECG), and had a normal troponin T and TTE. Later, brain imaging showed hemorrhagic conversion. Her proBNP peaked at 17,487 pg/mL and troponin T peaked at 0.41 ng/mL. Repeat TTE revealed a left ventricular ejection fraction (LVEF) 25% and apical hypokinesis with LVOT obstruction. She improved with a vasopressin infusion. A TTE four days later showed improvement of apical hypokinesis and LVEF 40%.

Takotsubo syndrome (TTS) is characterized by transient regional wall motion abnormalities of the right or left ventricle that is often preceded by stress. These abnormalities do not correlate with a single coronary artery distribution and typically there is no atherosclerotic coronary artery disease, hypertrophic obstructive cardiomyopathy, or myocarditis. The presentation mimics an acute myocardial infarction with ST-elevation or depression on ECG, and elevated cardiac biomarkers, in particular, an increased brain natriuretic peptic (BNP) to troponin ratio. Lastly, there is recovery of systolic function within three to six months.

The pathogenesis of TTS is multifactorial from myocardial damage due to catecholamine surge, coronary artery spasm, neurally mediated stunning, and genetics. It often occurs in postmenopausal women. As in this case, TTS should be considered in patients presenting with neurological injury and cardiogenic shock.

Abstract 213 Figure 1

Apical hypokinesis with preserved LV contraction at the base

214 A novel DLL4 intragenic deletion in an infant with adams-oliver syndrome and persistent truncus arteriosus with crossed pulmonary arteries

S Cheang*

H Meddaugh

S Samples

M Brumund

R Zambrano

T Kimball

Louisiana State University Health Sciences Center, New Orleans, LA

Introduction

Adams-Oliver syndrome (AOS) is a rare genetic disorder with an incidence of 1 in 225 000 individuals and is characterized by aplasia cutis congenita and terminal transverse limb defects. AOS is a clinically heterogenous disorder and cardiovascular malformations have been reported to occur in approximately 20% of these patients. To our knowledge, this is the first description of a newborn with AOS presenting with a DLL4 intragenic deletion and an unusual variant of truncus arteriosus.

Case Description

This female infant was born at term via a normal vaginal delivery. Physical exam was significant for cranial aplasia cutis congenita (ACC) with no other signs of dysmorphism or limb abnormalities. An echocardiogram done revealed a diagnosis of truncus arteriosus with both the pulmonary arteries arising anterolaterally and crossing one another as they coursed posteriorly. The echocardiogram also demonstrated a right aortic arch with an aberrant left subclavian artery. Pedigree analysis revealed that the patient’s father had tetralogy of Fallot (TOF) and absent fifth toenails bilaterally and the patient’s only sibling also had TOF with ACC and hypoplastic fifth toenails. The patient’s chromosome microarray and FISH for 22q11.2 deletion were negative. Whole exome sequencing identified a pathogenic deletion in DLL4 c.1857_1864delAGGGCCCC, p.P621AfsX12. This variant was also observed in the patient’s father and brother, consistent with a diagnosis of AOS type 6 in the proband and family.

Discussion

We present a case of AOS type 6 due to a novel intragenic deletion in DLL4, presenting with intrafamilial variability. 6 genes have been identified to be underlying AOS to date, including DLL4. Within the DLL4 gene, 14 pathogenic mutations have been identified prior to this novel intragenic deletion. Pathogenic variants in this gene are considered to affect the conotruncal musculature, likely contributing to the cardiovascular malformations seen in our patient’s family. Additionally, crossed pulmonary arteries are a rare vascular anatomic abnormality. This defect is known to be associated with various genetic syndromes but has not been reported in association with AOS.

215 Recalcitrant catecholaminergic polymorphic ventricular fibrillation

RD Coultas*

R Shukla

E Sadic

MB Omar

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 50 year old male with a history of generalized anxiety disorder was admitted with an acute anterior STEMI. He underwent successful percutaneous coronary intervention to the left anterior descending artery. On day 5 post revascularization, he had a sudden ventricular fibrillation (VF) cardiac arrest. Successful return of spontaneous circulation was obtained after defibrillation, however, only briefly. He subsequently developed a further 12 episodes of VF, each resolving only temporarily with defibrillation. The episodes had been unyielding despite adjunctive therapies with amiodarone, lidocaine and mechanical circulatory support. Finally, propofol infusion was initiated with resolution of incessant VF. Over the ensuing days he did not tolerate propofol weaning due to recurrent VF and electrophysiological study did not identify an endocardial substrate. Thus, robotic sympathectomy with resection of left stellate ganglion was pursued. Propofol and mechanical support was then able to be weaned without further episodes of VF. He was eventually discharged with an intracardiac defibrillator.

Abstract 215 Figure 1

Electrocardiogram captured during VT/VF storm showing degradation of sinus rhythm into polymorphic VT/VF

Discussion

Electrical storm is the phenomenon of incessant, episodic ventricular arrhythmias in a short time period. Catecholaminergic polymorphic ventricular tachycardia/fibrillation is a subtype that may be due to a congenital channelopathy or acquired by triggers such as acute myocardial ischemia. Episodes can be self-limited but termination of the storm often requires multiple antiarrhythmic drugs and/or defibrillation. In refractory cases like ours, salvage therapies with mechanical circulatory support, chemical sympathetic blockade with propofol or surgical stellate ganglion sympathectomy may be effective.

216 A case of recurrent spontaneous coronary artery dissection of the same vessel

D Daniels*

JD Pollard

University of Mississippi Medical Center, Brandon, MS

Case Report

Spontaneous coronary artery dissection is a very rare but increasingly more prevalent cause of acute coronary syndrome especially in young women < 60 years of age.1 One review in British Colombia found the incidence of SCAD to be 0.15 new cases per 10,000 people per year.2 Underlying inflammatory conditions such as systemic lupus erythematosus can certainly play a role in an increase incidence of SCAD. 38 year old African American female with history of systemic lupus erythematosus and lupus nephritis presented to the emergency room with ‘pressure-like’ left sided chest pain with radiation to the left arm and left side of her back. In the emergency room she was found to have a troponin of 0.25 and EKG with non-specific t wave abnormalities. Inflammatory markers were obtained and unremarkable at that time. She was taken for coronary angiography the next morning and found to have dissection of her distal RCA extending into the posterolateral branch. The decision was made to medically manage with dual antiplatelet therapy and follow up with repeat coronary angiography at a later date to track progression vs resolution. She underwent repeat coronary angiography about six months later and was found to have complete resolution of her dissection at that time. Around one year later, now at the age of 40 and one and a half years post her original episode of SCAD she presented to the emergency department with chest pain radiating down her left arm. EKG was consistent with inferior ST segment elevation consistent with acute myocardial infarction and she was loaded with aspirin and Brilinta, started on a heparin and nitroglycerin infusion and taken to the cath lab. In the cath lab she was found to have recurrent dissection of her right coronary artery in the mid-distal section of the vessel with active thrombosis present. The decision was made to medically manage with continued dual antiplatelet therapy and glycoprotein IIb/IIIa inhibitor post cath. This case is interesting as this patient did not only have recurrent SCAD but also there is documentation of complete resolution of previous dissection and then re-presentation with STEMI and further coronary dissection in same section of her RCA as her previous event

217 Right ventricular perforation in a patient with takotsubo cardiomyopathy: a case report

T Dixon1*

M Elmassry1

M Abohelwa1

E Elgwairi1

M Elmassry2

J Abdelmalek1

K Nugent1

1Texas Tech University Health Sciences Center, Lubbock, TX

2Leicester Royal Infirmary, Leicester, UK

Case Report

Introduction

Takotsubo cardiomyopathy (TCM) is a development of apical ballooning of the left ventricle and is characterized by reversible left ventricular dysfunction. Cardiac free-wall rupture (CR) is a rare, but fatal complication of TCM. We present a case of TCM complicated by right ventricle (RV) perforation.

Case presentation

A 71-year-old female with hypertension who was admitted for C. difficile sepsis and rhabdomyolysis after she was found down on the ground for 18h. She developed atypical chest pain and was hemodynamically stable. EKG showed diffuse ST-Elevation and Troponin was elevated at 3,000. Bedside echo showed apical and septal akinesis. Coronary angiogram was negative for obstructive CAD and left ventriculogram showed mid to distal akinesis with apical ballooning consistent with TCM. A few hours later she became hypotensive and tachycardic. Repeat echo showed large pericardial effusion with tamponade physiology. The patient underwent an emergent pericardial window, was found to have hemopericardium and further exploration showed 0.5 cm tear in the RV side of LAD which was repaired. The patient did well and was discharged home 8 days later.

Discussion

TCM is a reversible disease precipitated by acute physical or emotional stress. It presents with chest pain and dyspnea associated with ST-elevation and elevated cardiac enzymes. It is diagnosed by apical ballooning on Left ventriculogram. TCM usually has a good prognosis. However, rarely life-threatening complications like CR may arise. Most reported cases of TCM-induced CR involved the LV wall. However, RV involvement occurs in about 20% of cases as in our case. We believe that our patient‘s acute illness led to TCM-induced RV perforation and tamponade. Early diagnosis and prompt surgical repair are critical for patient‘s survival as in our case.

Conclusion

Cardiologists should be aware of the rare and fatal TCM complications like ventricular wall rupture. Early diagnosis and prompt surgical intervention could be lifesaving.

218 Lung herniation after forceful coughing

MH El-Farra1*

M Ali2

N Hasaniya1,2

1University of California Riverside, Riverside, CA

2Saint Bernardine Medical Center, San Bernardino, CA

Case Report

Introduction

Lung hernia is an abnormal protrusion of lung tissue through the boundaries of the thoracic cavity. It is commonly seen after chest trauma or thoracic surgery but rarely occurs spontaneously. We report a patient who presented with a lung herniation after vigorous coughing.

Case Presentation

A 70-year-old Hispanic male had a vigorous cough and shortness of breath for 15 days prior to admission. He presented with left chest pain aggravated by chest movement and breathing. Physical examination of the chest wall revealed large ecchymosis over the left anterior and lateral chest. Auscultation of the lungs revealed clear breath sounds bilaterally, but decreased air entry on the left lower side. The patient denied any popping sound or trauma to the left chest wall region. He was a former smoker but denied alcohol or drug abuse. Past medical history was significant for asthma, hypertension, and hyperlipidemia with no history of past chest surgery. Patient was morbidly obese with a BMI of 48.

Laboratory results showed white blood cell count was 14,800/mL, hemoglobin level of 10.7 gm/dL, hematocrit of 30.6%, prothrombin time of 12.7 seconds, and sodium level of 117 mmol/L.

A CT scan of the chest with contrast revealed a 4 cm left lung parenchyma herniation at the left 8th intercostal space through the lateral chest wall without signs of strangulation.

The patient was admitted with normocytic normochromic anemia and partial herniation of the left lower lobe of the lung with left side chest ecchymosis. It was decided to proceed with conservative management of compressive pads and anti-tussive medications due to the lack of major symptoms in his current state and no signs of strangulation of the lung. The patient was discharged home in a stable condition. On follow-up the patient continued to be stable, partial resolution of the chest ecchymosis and significant improvement of his shortness of breath and wheezing.

Conclusion

With no set guidelines on treatment of lung herniations, symptoms, site of herniation, and presence of strangulation must be considered when deciding the course of treatment. Conservative management is for uncomplicated hernias while surgical intervention is for complicated hernias.

219 Chylothorax post-coronary artery bypass grafting: surgical ligation of the thoracic duct

MH El-Farra1*

N Pham2

M Kajitani2

N Hasaniya1,2

1University of California Riverside, Riverside, CA

2Saint Bernardine Medical Center, Saint Bernardine Medical Center, San Bernardino, CA, US, hospital, San Bernardino, CA

Case Report

Introduction

Chylothorax post-coronary artery bypass grafting (CABG) is a rare complication. In CABG, the most common cause of thoracic duct injury is during the harvesting of the left internal mammary artery (LIMA). We present a case of chylothorax after coronary artery bypass grafting treated with surgical ligation.

Case Presentation

A 61-year-old female underwent a mitral valve repair and CABGx4 using a LIMA graft to the LAD artery. Initially, the patient did well postoperatively. However, on post-operative day 2, the patient began having a large amount of left pleural effusion drainage with chylous characteristics.

The patient was treated medically with fasting and total parenteral nutrition. On postoperative day three, the patient drained 2 L/day of continued chylous fluid. On postoperative day 4 the patient drained chylous milky colored fluid, and the patient’s serum triglyceride level dropped to 148. Conservative medical treatment was continued for two weeks without success. Surgical intervention was decided accordingly.

A redo sternotomy was preformed, and the mediastinum was explored. As suspected, there was a large amount of milky fluid gushing out from the top of the internal mammary artery (IMA) pedicle on the lateral edge adjacent to the left subclavian vein. The thoracic duct was carefully dissected along with isolation of the IMA pedicle from the left lung and mediastinal pleura. The leaking area was ligated with 5–0 Prolene pledgeted sutures, thus stopping any further chylous leakage. Doppler evaluation of the LIMA showed normal flow signal, ruling out injury to the LIMA. The sternum was closed in the standard fashion. The patient continued to be stable and drains were removed after 2 days. She had an uneventful recovery.

Conclusion

Clinicians should consider surgical ligation of the thoracic duct when there is a high chest tube output. Medical treatment has a high failure rate, and early embolization or surgical ligation of the thoracic should be considered to reduce hospital stay cost and morbidity.

220 A case of acute pericarditis due to covid-19 infection

AY Hammouda1*

S Durganna1

T Roca1

L Barr2

1University of Florida, Pensacola, FL

2Radiology Partners Inc, Pensacola, FL

Case Report

We present a case of a 3-year-old male with past history of VSD repair complicated by post-pericardiotomy syndrome and recurrent pericardial effusions who presented with pericarditis and pericardial effusion secondary to COVID-19 infection as the first presenting symptom.

Patient was brought to the ED for chest pain. Due to his history of pericardial effusion, CXR and ECHO were performed. A small pericardial effusion was found and patient was discharged on Ibuprofen and colchicine. Later that night the patient returned to ED after developing fever, chest pain and increased work of breathing.Repeat ECHO revealed the effusion to be larger and patient was admitted. COVID-19 screening was performed and was found to be positive. Patient was treated with toradol for 4 days till symptoms resolved and was discharged to follow up with his cardiologist.

The recent pandemic resulting from SARS-CoV2 (COVID-19) is a global concern. In children, a wide array of presenting symptoms are now documented. While the immune response to infection presents similarly to many other viral respiratory infections, there are increasing reports of other organ affection. The objective of this case report is to highlight the importance of considering COVID-19 infection in the differential diagnosis when a child presents with symptoms of viral illness in organs outside of the respiratory system so that the child is tested early, appropriate supportive care is initiated early and the number of unprotected contacts is minimized.

Abstract 220 Figure 1

CXR revealing enlarged cardiac silhouette

221 Potential risk during catheter-directed thromboltyic therapy and how to avoid it

R Hazam1*

A Hallak1

D Murray2

R Murray1

1Texas tech university health science center, Amarillo, TX

2University College Dublin, Dublin, Ireland

Case Report

Introduction: Although rare, some patients may have atrial septal defect which may complicate this procedure like Cather-directed thrombolysis.

Case

A 41 year-old male, diagnosed with submassive PE. Right heart catheterization with two angled pigtail catheters manipulated through the right heart to reach the right and left pulmonary arteries, however on frontal fluoroscopy the catheters appeared slightly more caudal than expected. Lateral fluoroscopy didn’t show the catheter going through the expected anterior curvilinear course of the right ventricle and pulmonary trunk. Contrast was injected into each pigtail catheter showed retrograde flow of contrast back into the left atrium, confirming that the catheters were in the pulmonary veins, passed through an ASD. Upon review of CTA chest, there was a visible ASD.

Discussion

Congenital heart defects are rare but can complicate certain procedures and interventionalists need to be aware of this possibility.

Catheter position more caudal than the pulmonary artery silhouettes should alert the operator to the incorrect placement in the pulmonary veins via an ASD.

In these circumstances, lateral fluoroscopy will show no catheters along the expected anterior curvilinear route of the right ventricle and pulmonary trunk. Contrast injection will show flow back to the left atrium rather than the flow away from the heart. Other potential confirmatory methods include pressure monitoring and blood gas sampling. In addition, careful scrutiny of the CT angiogram for an ASD prior to the procedure may alert the operator to this potential pitfall.

222 Total anomalous pulmonary venous return in a neonate

SE Hudson*

UAB (University of Alabama at Birmingham), Birmingham, AL

Case Report

Infant female born at 32.6wga to 30yo P0101 via SVD 2/2 preterm labor was noted on prenatal US to have mild right atrial dilation. At birth patient immediately required positive pressure ventilation and later was intubated for poor respiratory effort. CXR demonstrated abnormal density in right lower lobe concerning for diaphragm eventration vs. congenital diaphragmatic hernia. Echocardiogram demonstrated unobstructed total anomalous pulmonary venous return (TAPVR) to confluence draining directly to right atrium posterior to the right superior vena cava (SVC), along with atrial septal defect (ASD) with right to left shunting, moderate perimembranous ventricular septal defect (VSD), and systemic venous abnormalities including bilateral SVC, left SVC to coronary sinus, interrupted inferior vena cava (IVC) with hemiazygos vein draining to left SVC, hepatic veins draining to right atrium. CT angiogram later obtained confirming anatomy. Given prematurity and unobstructed nature of TAPVR, patient monitored for weight gain prior to surgical repair.

Teaching Points include: Diagnosis of TAPVR and different types (supracardiac, infracardiac, cardiac). Differentiating obstructed vs. unobstructed. Typical management strategies (surgery; waiting in this case given prematurity/weight). Unusual case given additional systemic venous anomalies. Images will be utilized in poster/presentation from echocardiogram obtained during the neonate’s admission process.

223 E-L mitral inflow velocity masquerading as e/a pattern on echocardiography in a patient with atrial flutter

I Ifedili*

T Fan

The University of Tennessee Health Science Center, Memphis, TN

Case Report

Atrial flutter (AFL) carries an increased risk of stroke. Anticoagulation is indicated in patients with elevated CHA2DS2VASc risk score. Echocardiography (ECHO) is useful for distinguishing AFL from other atrial arrhythmias. Pulsed wave (PW) Doppler on ECHO showing an E/A mitral inflow pattern can exclude the diagnosis of AFL. A less known E-L mitral inflow pattern can occur in patients with AFL, leading to inaccurate atrial rhythm diagnosis and incorrect grading of diastolic dysfunction.

An 82-year-old male with history of coronary artery disease, heart failure, AFL and diabetes mellitus, came to the ECHO lab for chest pain workup. He had an EKG rhythm similar to when the diagnosis of AFL was made. PW Doppler of the mitral inflow velocities on ECHO (figure 1) gave the impression of an E/A pattern typical of sinus/atrial rhythm. Search for other features of AFL on ECHO, lead to the conclusion that the rhythm was indeed AFL. L wave masquerading as an A wave lead to an uncertainty in the diagnosis of his rhythm.

The E/A pattern is caused by the combination of the early passive filling of the left ventricle from left atrium (E) followed by an active filling from organized atrial contraction (A). This should be distinguished from an L wave which represents pulmonary vein mid diastolic flow through the left atrium into the left ventricle after early rapid filling.

A prominent L wave can masquerade as an A wave in patients with AFL, leading to inaccurate rhythm diagnosis. Careful observation of other parameters in ECHO is necessary to avoid this pitfall.

Abstract 223 Figure 1

Pulsed wave Doppler showing an E-L pattern of mitral inflow velocity in a patient with atrial flutter

224 Congenital long qt syndrome masquerading as epilepsy

N Maaliki*

S Mikulic

W Kogler

MB Omar

University of Florida Health at Jacksonville General Medicine, Jacksonville, FL

Case Report

Introduction: Congenital Long QT Syndrome Type 3 is a cause of arrhythmias. While it can lead to sudden cardiac death, it may elusively present with neurologic symptoms.

Case

A 33-year-old man with a history of a ‘seizure disorder’ was admitted after a cardiac arrest. He had been found apneic during sleep, after which he was noted to be in pulseless polymorphic ventricular tachycardia that resolved after defibrillation. Subsequent Electrocardiogram (ECG) revealed a markedly prolonged QTc of 640/584 ms. Left heart catheterization and cardiac MRI were unremarkable. A subcutaneous ICD was placed, and he was started on Nadolol. The patient reported a history of random syncopal events since the age of 12, which occurred without prodromal symptoms and were immediately followed by tonic-clonic seizure activity. Genetic testing revealed an SCN5A mutation consistent with Long QT Syndrome Type 3 (LQT3)

Discussion

LQT3 is the third of congenital long QT syndromes. It is an autosomal dominant channelopathy identified by a mutation of the SCN5A gene, which encodes a cardiac sodium channel’s alpha-subunit. This results in a prolonged action potential, which leads to a long QTc interval. Clinically, this manifests as an increased risk of ventricular arrhythmias and sudden cardiac death that usually occur within the first three decades of life. LQT3 commonly presents with arrhythmogenic syncopal or seizure-like episodes during childhood, leading to multiple missed diagnoses. The QTc interval prolongation correlates with bradycardia, which explains the high proportion of arrhythmias during sleep. The diagnosis is made through a detailed history and 24-hour 12-lead ECG monitoring, followed by genetic testing. LQT3 can be treated with beta-blockers, class 1 agents, and an ICD in severe cases.

225 Paroxysmal supraventricular tachycardia in seronegative kawasaki disease like multi-system inflammatory syndrome in children

C Manjunath*

O Sanchez

University of South Alabama, Mobile, AL

Case Report

Multi-System Inflammatory Syndrome in Children (MIS-C) is the presence of persistent fever with elevated inflammatory markers with evidence of organ dysfunction. Its presentation is highly variable and overlaps with Kawasaki disease. Ventricular dysfunction is the most common cardiac manifestation in MIS-C. In a study in Italy, only 2 out of 10 patients who had MISC did not test positive for either IgG or IgM. Considering the temporal relationship with the current SARS-CoV-2 pandemic high index of suspicion is indicated to capture and report unusual presentations of it even in seronegative cases.

We present a rare case of an 8-month-old male child who was admitted for concerns of Kawasaki disease with continuous fever for two-weeks with diarrhea, cough, runny nose, edematous extremities, diffuse macular rash, bilateral erythematous conjunctiva, and oral mucosa. In a febrile event patient presented with supraventricular tachycardia (SVT) associated with desaturation that required transfer to the Pediatric Intensive Care Unit (PICU) for further care. Sinus rhythm was restored after 3 doses of adenosine and 1 synchronized cardioversion. Echocardiogram evidenced mild mitral regurgitation with small pericardial effusion without any coronary dilation or aneurysm. The patient met MIS-C criteria and he had exposure to SARS-CoV-2 infection in the past 3 wks. Multiple SARS-CoV-2 Protein Chain Reaction tests and antibody tests were negative. He was treated with immunoglobulin infusion and high dose aspirin. He did not require a second dose of immunoglobulin infusion or any second-line treatment. The patient recovered well and was discharged home with propranolol although no abnormal basal rhythm was identified.

Supraventricular tachycardia is an unusual presentation for either Kawasaki Disease or SARS-CoV-2 related MIS-C. Although both entities overlap, they are not mutually exclusive and treatment is similar if not the same. As pediatricians, prompt initiation of treatment and a higher level of monitoring should be considered with suspected Kawasaki disease or suspected MIS-C since we are still learning about its presentation. In our patient, the lack of laboratory confirmation of SARS-CoV-2 does not rule in or rule out any of the conditions.

226 Phantom tumor: ‘now you see me, now you don’t’

J Martinez*

JG Rodriguez Velez

Hospital Municipio de San Juan, San Juan

Case Report

An 89 year old female with pertinent medial history of hypertension who presented at the emergency clinic with complaint of shortness of breath which had progressive worsen in a 2 day period. She referred several months history of dyspnea on exertion with associated chest tightness, orthopnea, paroxysmal nocturnal dyspnea and leg swelling. Physical examination remarkable for jugular venous distention, weight loss, bibasilar crackles, and trace pitting edema.

Initial workup including chest X-Ray remarkable for right upper lobe space occupying mass and elevated BNP levels. Chest CT-scan significant for cardiomegaly, bilateral pleural effusion and low density mass at the interfissural region suggestive of tumor. 2D-ECHO consistent with heart failure with reduced ejection fraction. Patient was started on an aggressive diuretic regimen and restrictive fluid intake. After 5 days of inhospital management patient symptoms had significantly improved. Subsequent chest X-Ray were remarkable for almost complete resolution of tumor like right lung lesion.

Localized interlobular effusions (also known as phantom tumor) is a mass-like interlobular fluid collection rarely seen on imagine workup in patients presenting with decompensated congestive heart failure. This imagine findings vanishes after appropriate management. Disappearance of lesion after diuretic therapy tends to confirm the diagnosis. Due to its unease appearance but easily manageable treatment considering phantom tumor under the confounding presentation of a possible lung tumor in a decompensated heart failure patient may prevent unnecessary, expensive and possibly harmful diagnostic and treatment errors.

Although well-known phenomenon, Phantom Tumor is a condition that can be easily confuse and result in unnecessary hospital resource misuse and money expense. Not to mention increasing the risk of placing the patient to unnecessary radiation or invasive procedures. By making primary physician more aware of this diagnosis, we decrease the probability of missing this easily treated complication of decompensated congestive heart failure and avoid consulting or referring the patient to high cost subspecialties. Being said this; primary care physician can treat phantom tumor in a non-sophisticated facility with just x-ray equipment and loop diuretic therapy.

227 Large tricuspid vegetation in a previously healthy ten-year-old male

K McKnight*

K Singhapakdi

KP Sharma

C Gavrilita

USA Children’s and Women’s Hospital, Mobile, AL

Case Report

Infective endocarditis (IE) is relatively uncommon in children, especially in those with structurally normal hearts. When present, however, it is important to identify and treat IE promptly due to its ability to cause significant damage to the endocardial tissue and heart valves and its significant mortality rate. Here we will describe a previously healthy pediatric patient with a structurally normal heart who was found to have IE, with a very large vegetation on his native tricuspid valve. However, he did not exhibit any of the classic findings of IE (no Janeway lesions, Osler’s nodes, or splinter hemorrhages), and the vegetation formed on the right side of his structurally normal heart, in the absence of cardiac and social risk factors (e.g. no IV drug use). This case demonstrates that clinicians should always have a high index of suspicion for IE in the setting of bacteremia and fever, even in the absence of a classic history of physical exam.

Abstract 227 Figure 1

A 10 × 24 mm vegetation is on the atrial side of the septal leaflet of the tricuspid valve

Abstract 227 Figure 2

After treatment, there is no evidence of a vegetation on the tricuspid valve

228 A rare and mixed etiology of cardiac tamponade

S Mikulic*

P Dhruva

F Kandah

B Attarha

F Rollini

University of Florida Health at Jacksonville, Jacksonville, FL

Case Report

A 37-year-old female with pmh significant for Graves disease s/p ablation with resultant hypothyroidism was admitted at 20 weeks’ gestation for pre-eclampsia. The patient presented with abdominal pain and dyspnea. During evaluation she had significantly elevated TSH and undetectable free T4. She ruled in for pre-eclampsia with severe features due to blood pressure criteria and proteinuria. In addition, a TTE revealed moderate pericardial effusion. A pericardiocentesis removing 700cc of yellow fluid was performed, and the patient was started on levothyroxine. Analysis of serous fluid proved to be inconclusive. Further workup for etiologies of the effusion such as viral, bacterial, and autoimmune causes were negative. One week later, the patient had a recurrence of the pericardial effusion, along with hemodynamic compromise. A pericardial window was placed with 500cc of fluid removed. Due to worsening of symptoms the pregnancy was terminated. She was eventually discharged medically stable, and to date has experienced no recurrence of symptoms.

Our case presents a unique scenario in which two uncommon etiologies of pericardial effusions presented simultaneously to result in tamponade. Hypothyroidism can lead to a pericardial effusion in 3–6% of cases. The pathophysiology is suspected to be secondary to increased permeability of the pericardial capillaries to albumin, leading to increased colloid pressure within the pericardium, and therefore decreased colloid osmotic pressure gradient between the pericardial space and pericardium. Although hypothyroidism is a much more common etiology in leading to pericardial effusions, pre-eclampsia has also been reported as a cause in the medical literature, likely from generalized capillary leak due to endothelial cell dysfunction and reduced intravascular oncotic pressure.

This case highlights the importance of keeping a broad differential and performing a thorough investigation in determining the etiology of a pericardial effusion. In a patient with risk factors for developing a pericardial effusion, close observation with serial echocardiograms should be performed for early detection and prevention of cardiac tamponade, as the result may prove fatal.

229 Systemic inflammatory response syndrome after cardiac arrest

JR Padgett*

C Latour

JD Pollard

University of Mississippi Medical Center, Brandon, MS

Case Report

Introduction

Shock following sudden cardiac arrest due to myocardial infarction is usually thought to be cardiogenic in nature. However, systemic inflammatory response syndrome is possible after cardiac arrest. We present a case with MI and cardiac arrest and subsequent SIRS, discuss the proposed mechanism, and the importance of recognizing SIRS as a complication post cardiac arrest.

Case

A 72 yo female with pmh of CAD, T2DM and PAD presented to our hospital with chest pain and elevated troponin level. Coronary angiography revealed a thrombus with dissection in the right coronary artery. She received PCI x 4. After procedure, she had cardiac arrest with polymorphic VT requiring CPR and defibrillation with ROSC and no intubation. The next day she had short VT arrest with ROSC requirin intubation. Afterwards, she became hypotensive with vasopressor requirement and AKI. She developed 2:1 AV block with bradycardia requiring dopamine. Echocardiogram showed inferior wall motion abnormalities, LVEF 35% with RV dysfunction. Due to ventricular arrhythmias, AV block and shock, initial management was for cardiogenic shock secondary to RV infarction. She did not respond clinically to this management. Further workup later suggested distributive shock. Therapy was targeted for distributive shock and she made some improvement. Unfortunately, she had further refractory shock and expired. No clear source for sepsis was identified.

Discussion

Cardiac arrest with whole body ischemia and reperfusion syndrome can cause postresuscitation disease. Postresuscitation abnormalities after arrest can mimic severe sepsis. Both are characterized by high levels of circulating cytokines, plasma endotoxin and dysregulated leukocyte production of cytokines. [1] One study showed coagulation abnormalities after cardiac arrest where the thrombin-antithrombin complex was consistently elevated and protein C and S were decreased. [1]

Conclusion

Right ventricular infarcts may manifest as cardiogenic shock, and can be complicated by ventricular arrhythmias with cardiac arrest and high degree AV block. However, it is also important to note that patients with post cardiac arrest can have SIRS response due to whole body ischemia and reperfusion.

230 Takotsubo cardiomyopathy and qt-prolongation following a cerebrovascular accident

I Pour-Ghaz1*

S Khan1

T Fan1,2

AB Katwal1,2

RN Khouzam1,3

AA Adeboye1

1The University of Tennessee Health Science Center, Memphis, TN

2Memphis VA Medical Center, Memphis, TN

3Methodist University Hospital, Memphis, TN

Case Report

Background: Takotsubo cardiomyopathy (TCM), or left ventricular (LV) ballooning syndrome, is a transient LV dysfunction in the apical or mid-ventricular segments usually provoked by physical or emotional stress seen on echocardiogram (ECHO). It is thought to be induced by catecholamine release and microvascular dysfunction. TCM can cause electrocardiographic (ECG) changes, chest pain, and myocardial enzyme release. Here we present a case of TCM with extreme QT prolongation following a cerebrovascular accident.

Case Presentation

The patient is a 72-year-old male with a past medical history of end-stage renal disease and hypertension who developed left-sided hemianopsia and neglect. Tissue plasminogen activator was administered after brain imaging. ECG showed prolongation of QT from 458 ms to 706 ms (figure 1). Same-day ECHO showed an ejection fraction of 55–60% with a moderate-sized akinetic apical wall motion abnormality, mostly resolved on the fourth day. Possible offending medications were stopped. Troponin levels were minimally elevated and peaked at 0.519 ng/mL. There were no significant electrolyte abnormalities.

Abstract 230 Figure 1

ECG post tPA

Conclusion

Prolonged QT increases the risk of developing dysrhythmias; thus, timely recognition is critical. Here we presented a case of extreme QT prolongation after an acute stroke with ECHO findings of TCM. Appropriate care was provided by the utilization of ECG, ECHO, and timely studies. This is one of the few incidences of extreme QT prolongation in TCM with optimal outcomes through well-coordinated medical management.

231 Post maze and mitral valve annuloplasty atrial flutter ablation using three dimensional carto mapping system

K Sawalha*

D Nair

White River Health System, Batesville, AR

Case Report

Introduction

Over the past two decades Maze procedure has become the gold standard treatment for medically refractive atrial tachyarrhythmias (ATA) as it creates a functional myocardium for a proper depolarization of the atrium. Despite this, patients may still have recurrent atrial arrhythmias including AF, typical flutter, atypical atrial flutter and focal atrial tachycardias. Such patients may be candidates for electrophysiology study and catheter ablation. We present this case of atrial flutter post-Maze procedure in a repaired mitral valve with annuloplasty that was treated with catheter Radiofrequency Ablation (RFA) using three- dimensional CARTO mapping system.

Case Presentation

A 60-year-old male patient with a past medical history of paroxysmal atrial fibrillation status post cardioversion and Sick Sinus Syndrome with pacemaker presented for atrial tachycardia catheter ablation. He had a history of mitral valve regurgitation that was repaired with annuloplasty with subsequent MAZE procedure. Patient’s medications include Sotalol, Coreg, Xarelto and aspirin for anticoagulation. Device interrogation showed 100% atrial tachycardia. Intracardiac echocardiogram showed Ejection fraction of 60–65% with severely dilated left atrium and mitral annuloplasty in place. Patient had successful isolation of all four pulmonary vein and termination of his atrial flutter using 3D CARTO mapping system with no complications or return of the arrythmia on follow up visits.

Conclusion

Even though MAZE procedures designed to restore normal sinus rhythm, post-operative ATA including Atrial Fibrillation and Atrial Flutter may still occur. In most patients, these procedures are employed as adjunctive therapy in patients undergoing other cardiac surgeries such as mitral valve as seen in this case or coronary artery bypass surgery. Patients with recurrent ATA after surgical ablation may be candidates for electrophysiology study and catheter ablation using advanced mapping systems that uses 3D images for better outcomes.

232 Spontaneous coronary artery dissection in a postpartum female

J Sekhon*

B Rogers

S Siddiqui

Texas Tech Health Sciences Center, Lubbock, TX

Case Report

Spontaneous coronary artery dissection (SCAD) is an extremely uncommon cause of myocardial infarction, occurs predominantly in women during or after pregnancy. The exact etiology is unknown. Here we present a case of SCAD five days postpartum.

29-year-old Hispanic female G2P2 (gravida 2, para 2), was discharged home after an uneventful full-term vaginal delivery of a healthy baby boy, no prior medical history and no history of smoking. Five days postpartum she presented to emergency center (EC) with acute onset sharp chest pain radiating to bilateral arms and upper back at rest. Lab work showed elevated high sensitivity troponin T 6378 (normal high 19 ng/L), EKG with sinus tachycardia, ST elevation 1.5 mm V2-V3, 1 mm V4-V6, and Q wave in II, III, aVF, V1-V4. Transthoracic echocardiogram with ejection fraction (EF) 25–29% with severe hypokinesis. Taken to the catherization lab emergently for left heart catherization (LHC) showed type II SCAD involving proximal to distal left anterior descending (LAD) and proximal large D1 with TIMI III flow and severe mitral regurgitation. Started on medical management with aspirin 81 mg, lisinopril 5 mg twice daily, metoprolol succinate 25 mg daily, torsemide 5 mg daily, and rosuvastatin 40 mg daily. She was fitted for LifeVest secondary to low EF and discharged home with close follow up with cardiology along with counseling about future pregnancies.

Abstract 232 Figure 1

EKG on admission

Spontaneous coronary artery dissection has been reported as a cause of myocardial infarction in females during pregnancy or postpartum. The left coronary artery is most commonly affected and typically arises within 2 cm of the aortic ostium. Multiple hypothesis have been proposed but the pathogenesis of coronary artery dissection is still unclear. However, multiparity and advancing age have been reported to be at increased risk. Management can vary patient to patient but can consist of intravenous heparin, nitroglycerin, aspirin, statin, and pain management. Thrombolytics are contraindicated in these patients.

233 Chasing the etiology of cardiac tamponade- when pericardial effusion is a red-herring

T Sharma*

F Habash

H Salah

A Lopez-Candales

University of Arkansas for Medical Sciences, Little Rock, AR

Case Report

We present the case of a 54-year-old lady with squamous cell carcinoma of the retromolar trigone with metastasis to mediastinal lymph nodes, who presented with hypotension and altered mental status. She had a recent history of bacterial pericarditis causing cardiac tamponade, for which she underwent pericardiocentesis and adequate treatment with antibiotics. On current presentation, bedside echocardiogram showed a large fluid collection anterior to the heart and decreased cardiac wall motion. CT scan of the chest was reported as nodular pericardium with surrounding low attenuating fluid collection and causing tamponade effect. Due to the acute presentation and hypotension, patient was taken to the cardiac surgery OR where a window was created, and a drain was placed into the fluid collection draining 350 cc of purulent fluid. On further review of the echocardiogram and CT scan, the fluid collection was recognized to be outside the pericardium and was indeed causing mass effect tamponade.

In this patient with recurrence of pericardial effusion causing tamponade, it is likely that tamponade could be due to recurrence of pericardial effusion. Yet, a necrotic mass in the anterior mediastinum may cause mass effect and tamponade. Identifying the cause of tamponade is crucial as it could signify a progression of the metastatic disease with poor prognosis for survival. In conclusion, anterior mediastinal masses can cause cardiac tamponade and should not be deemed as a by-stander in the presence of a pericardial effusion.

Endocrinology and metabolism

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
234 Diabetic ketoacidosis in covid-19 patients

K Ali*

S Rao

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Diabetic ketoacidosis (DKA) is a common condition causing hospitalization and mortality in patients with Type 1 and Type 2 diabetes. In the current COVID-19 pandemic, diabetes is a risk factor for poor outcomes in hospitalized patients. Early reports have indicated that COVID-19 patients with Type I Diabetes and DKA had longer lengths of stay, increased rates of ARDS, and higher mortality rates. This study explores those claims.

Methods Used

Our study includes 7 COVID-19 positive DKA patients and examines various demographic parameters, laboratory values, and outcomes.

Methods

The Infectious Disease and Control office at University Medical Center in Lubbock, Texas, provided a list of patients with a COVID-19 infection hospitalized between March 1 and July 20, 2020. The medical records were reviewed to collect information on age, gender, history of diabetes, laboratory tests pertinent to DKA, and outcomes.

Summary of Results

This study includes 7 patients with median age of 39. Three patients (42.9%) were males. The median admission BMI was 29.44 kg/m. Six patients (85.7%) had a history of diabetes mellitus; the median hemoglobin A1c was 12.8% (available in 5 patients). The median admission glucose level was 311 mg/dL with a median anion gap of 21 meq/L. The median pH was 7.25 (7 patients). All patients were managed with insulin infusions, and the median time until the anion gap closed twice was 48 hours. The median fluid balance during insulin infusion was 5,660 mls. Two patients (28. 6%) required mechanical ventilation during their hospitalization. No patients required vasopressors or renal replacement therapy. The median length of hospital stay was 4 days; the mortality rate was 14.3%.

Conclusions

Most patients with DKA and COVID-19 in this study had poorly controlled diabetes. They presented with typical laboratory results seen in other patients with DKA without COVID-19 and responded well to intravenous insulin and fluids. Except for one patient, the length of stay was relatively short. This study suggests that patients with diabetes admitted the hospital with COVID-19, especially patients with poorly controlled diabetes, should be screened for DKA and monitored for its development during hospitalization.

235 A case of high insulin resistance and shifting hhs to dka diagnoses

M Bell*

K Mentore

LS Engel

T DeSilva

LSU Health Sciences Center, New Orleans, LA

Case Report

Hyperglycemic crises, Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmotic State (HHS), are the most severe manifestations of Type 1 (T1DM) and Type 2 Diabetes Mellitus (T2DM), and can result in morbidity and mortality for patients.

Case

A 27 year old morbidly obese man presented to the hospital with polydipsia, polyuria, blurry vision and nausea and was found to have a blood glucose of 998 mg/dL and serum osmolality of 338 mOsm/kg and anion gap of 16, bicarbonate of 22 and beta-hydroxybutyrate of 1.9 mmol/L. After initial medical management for HHS with fluids and subcutaneous insulin, and apparent improvement, the patient developed altered mental status and was found to be in DKA, requiring the intensive care unit, insulin gtt and up to 870 units of insulin in one day. His metabolic encephalopathy resolved and he was able to resume an oral diet with blood glucose control.

Discussion

DKA and HHS are metabolic hyperglycemic crises that are managed with subtle differences, as the main driving force of morbidity/mortality for HHS is volume depletion secondary to hyperglycemia, volume repletion and close monitoring of electrolytes, specifically potassium, are the mainstays. Therapy for DKA, on the other hand, is focused on resolution of acidosis as the main force for damage, with insulin, volume repletion and close monitoring of electrolytes. The commonality is close monitoring of acidosis status and electrolytes. Our patient seemed to shift from an HHS presentation to DKA likely secondary to high insulin resistance in the presence of glucose toxicity. Had closer monitoring been enacted, the transition may have been avoided. This case illustrates the importance of understanding the pathophysiology of DKA vs HHS and close monitoring of blood glucose and electrolytes as patients can shift from one to the other without proper management.

236 Protocol based standardized endocrinological evaluation of children with traumatic brain injury: a qi initiative

J Bhat1*

SC Schultz2

R Gomez1

1Louisiana State University Health Sciences Center, New Orleans, LA

2CHNOLA, New Orleans, LA

Purpose of Study

Traumatic brain injury (TBI) can disrupt the hypothalamo-pituitary axis, causing central neuroendocrine dysfunction and hormone abnormalities (HPAD). As one-third of children can develop post-traumatic HPAD, a longitudinal and thorough follow up may be required to exclude the transient or late-onset HPAD.

Objective

To implement a protocol for standardized evaluation of children with TBI for the diagnosis of HPAD and to effectively establish a regular inpatient endocrine consultation and outpatient longitudinal follow up.

Methods Used

The study is divided into pre-QI (baseline phase) and QI phase (post-intervention phase). During the pre-QI phase, retrospective data were collected on children admitted with TBI at our institution for 1 year. The prevalence of HPAD and the percentage of children longitudinally followed in endocrine clinic were estimated. A consensus-based protocol, detailing clinical and hormonal assay-based evaluation at presentation and during the follow up were formulated and implemented. Prospective data collection will be performed to estimate outcome measures (prevalence of HPAD, rate of initial endocrine consultation and endocrine outpatient follow up) and process measure (protocol adherence rate).

Summary of Results

During the pre-QI phase, a total of 27 children, aged ≤19 years were admitted in the year for TBI management. The median (IQR) age at TBI diagnosis was 9 (3, 15) years. Motor vehicle accident was the predominant cause, accounting for 60%. In 85% of patients, the TBI was classified as severe based on GCS. Overall, only 8 children (30%) underwent limited (non-consultation based) endocrine evaluation (7 for central DI and 1 for central hypothyroidism) and 1 patient had complete evaluation (endocrinologist consulted). During the baseline period, the prevalence of transient central DI was diagnosed in 1 patient (4%). Implementation of protocol and post-intervention data collection is pending.

Conclusions

The lower prevalence rate of HPAD in the current cohort of TBI patients may be due to under evaluation for endocrine dysfunction. QI initiative incorporating standardized evaluation using protocol will improve identification follow up rates of patients with endocrine dysfunction following TBI.

237 Symptomatic clinical variant galactosemia carrier in a 2-month-old girl with normal newborn screening

CI Chinchilla Putzeys*

F Al-Saygh

MR Roca Garcia

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

Galactosemia is an autosomal recessive disease caused by a mutation leading to decreased activity of Galactose-1-phosphate uridylyl transferase (GALT) enzyme. If not treated, can cause serious complications such as failure to thrive, hepatocellular damage, infantile cataracts, intellectual disability and is associated with E. coli infections.

An 8-week-old African-American female presented with fever, decreased appetite, vomiting, and diarrhea. On examination, the patient had increased work of breathing, tachycardia, and signs of dehydration. Inflammatory markers were elevated and coagulation profile was slightly prolonged requiring vitamin K. Urine and blood cultures grew E. coli requiring an antibiotic course. Lumbar puncture was normal.

Two weeks later the patient was re-admitted for E. coli bacteremia and urinary tract infection. Voiding cystourethrogram was remarkable for grade 3 vesicoureteral reflux. Immunoglobulin levels were unremarkable.

Recurrent E. coli sepsis prompted testing for galactosemia despite her negative newborn screen at 15 days old. Her GALT enzyme activity was reduced at 14.3µmol/g of hemoglobin (normal ≥19.4µmol/g of hemoglobin). GALT gene sequencing resulted in one copy of the pathogenic variant p.Ser135Leu. Therefore, this patient is a heterozygous carrier of clinical variant galactosemia. Homozygosity for p.Ser13Leu is a prevalent cause of symptomatic galactosemia in African Americans. There is limited data for galactosemia carriers presenting with symptomatic galactosemia; however, this patient shows symptomatic galactosemia with recurrent E. coli sepsis despite being heterozygous for p.Ser13Leu mutation.

238 A case of wernicke’s encephalopathy in the presence of thyrotoxicosis

C Cunningham*

K Oakden

D Matrana

LS Engel

S Walvekar

LSU Health Sciences Center, New Orleans, LA

Case Report

Wernicke’s encephalopathy, characterized by a classic triad of nystagmus, ataxia, and confusion, is a neurological condition resulting from thiamine deficiency.

Case

A 30-year-old woman with a history of hyperthyroidism presented to a rural hospital with lower extremity weakness, shortness of breath, and subjective fevers with diaphoresis. At that time she appeared alert, interactive, and oriented. She was notably tachycardic and labs demonstrated a TSH of less than 0.01 uiU/mlwith a an elevated free T4 of 4.35 mg/dl. Prior to transfer, she received beta blockers for her tachycardia and methimazole for presumed thyroid storm. Upon arrival to our hospital, she was febrile to 105° F and tachycardic to 162 beats per minute. She was disoriented and hallucinating. Exam revealed horizontal nystagmus. Labs again demonstrated an elevated free T4 but now showed a lactic acidosis. She received propranolol and PTU for her thyrotoxicosis. After hospital day 2, the patient was no longer hallucinating but remained disoriented despite her approaching euthyroid levels. The persistence of her altered mental status despite treatment of the thyrotoxicosis was concerning. EEG and MRI brain were both unrevealing. During her prolonged hospitalization, it became clear that the patient’s altered mental status was consistent with confabulation which paired with her persistent nystagmus was concerning for potential Wernicke’s encephalopathy. High dose thiamine was started and serum levels were collected. Her mental status and nystagmus improved slowly with supplementation. Suspicion for Wernicke’s was confirmed when her thiamine level returned low at 29 nmoles/L.

Discussion

Wenicke’s encephalopathy is frequently overlooked in the nonalcoholic patients presenting with altered mentation. Thyrotoxicosis induces the Krebs cycle to utilize thiamine. Once thiamine is no longer available, the body shifts to anaerobic metabolism resulting in the production of lactic acid as seen in this patient. Wernicke’s encephalopathy, a severe neurologic condition caused by the exhaustion of thiamine reserves, can result in debilitating neurological complications and death if not properly recognized and treated early.

239 Pediatric seizures in the setting of a febrile illness: an unexpected diagnosis of rickets

R Dean*

GB Maniam

P Pungwe

A Batson

S Tijani

A Lunsford

Texas Tech University Health Sciences Center, Fort Worth, TX

Case Report

Rickets is a childhood disease in which bony mineralization dysfunction occurs secondary to hyperparathyroidism due to a deficiency of vitamin D. The most common presentation includes skeletal findings and developmental delays. This case discusses a diagnosis of rickets presenting as hypocalcemic seizures in the setting of febrile illness.

A 12-month-old boy presented to his pediatrician after having had seizure activity the night before. He was born at 39 weeks of gestation with an unremarkable delivery and newborn screening tests. On the evening prior to presentation, the patient had become febrile – and that night, he had had a sudden-onset generalized tonic-clonic seizure before falling back asleep. The patient was brought to the outpatient clinic the next morning and diagnosed with otitis media and a simple febrile seizure. He was prescribed amoxicillin and supportive management, but on the way home had another seizure. He was rushed to the emergency department, where laboratory tests revealed critical hypocalcemia. Physical examination findings showed frontal bossing, craniotabes, enlargement of the bilateral wrists at the metacarpophalangeal joints, and mild anterior bowing of tibia bilaterally on weight-bearing. The CMP revealed an elevated alkaline phosphatase level, an elevated parathyroid hormone level, and a decreased level of 25-hydroxyvitamin D. Electrocardiography showed prolonged QT intervals. Emergent repletion of calcium was started with intravenous calcium gluconate; he was also started on oral cholecalciferol and oral calcium carbonate. Oral amoxicillin was continued for right otitis media. A radiologic skeletal survey demonstrated abnormal bone mineralization, fraying, splaying, and cupping of numerous sites bilaterally (femora, tibiae, fibulae, radii, ulnae). There was also mild anterior rib end expansion at the costochondral junction bilaterally. After three days of hospitalization, the patient was discharged on oral calcium carbonate with follow-up outpatient appointments.

While the initial presentation of rickets presenting as hypocalcemic seizures in the setting of a febrile illness is rare, previously reported cases suggest that febrile seizures warrant detailed physical examination for bony abnormalities.

240 Implementation of congenital hypothyroidism screening protocol in community hospital neonatal intensive care units

DR Dhoot*

TO Findley

A Shah

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, Houston, TX

Purpose of Study

Congenital hypothyroidism (CH) is a preventable cause of intellectual disability and detectable on newborn screening (NBS). Preterm infants have a high rate of inaccurate results on NBS compared to term infants due to thyroid dysmaturity, underlying illness and delayed TSH surge. A screening protocol for preterm infants was created at an academic institution and introduced to two community neonatal intensive care units (NICUs). Our aim is to evaluate the feasibility and adherence to the guideline in the community setting.

Methods Used

A retrospective review was conducted at two community NICUs including preterm infants (≥23 to <35 weeks’ gestation) admitted between June 2018 and June 2020 in Houston, Texas (n=575). Data collected included associated genetic conditions, NBS results, free thyroxine and TSH levels. The protocol recommends obtaining thyroid function tests (TFTs) at ~30 days of life with monitoring and/or endocrine consult based on results and corrected gestational age (GA).

Summary of Results

The cohort of neonates had a median GA of 33 2/7 weeks with interquartile range (IQR) 31 1/7-34 2/7 and median birth weight of 1950 g with IQR 1470–2290. TFTs were collected at ~30 days of life in 206 out of 274 (75%) preterm infants that were admitted for at least 21 days. The median number of TFTs done per baby was 1 with a range of 1–5. 38 out of 274 infants (14%) and 31 out of 274 (11%) had abnormal first and second NBS for CH, respectively. In infants less than 28 weeks GA, incidence of abnormal first and second NBS for CH was 50% and 46%, respectively. Subsequent initial TSH levels obtained for those infants were normal (0.5–6 uIU/mL). Hypothyroidism was detected by the screening protocol in one neonate who was started on levothyroxine for medical treatment. This infant was born at 25 6/7 weeks GA and was diagnosed with an atrial septal defect. Results of the first and second NBS were abnormal for CH (reported as ‘TSH slightly elevated’).

Conclusions

Implementation of this protocol in community hospitals affiliated with an academic institution demonstrates its practicality. Many community NICUs have limited access to pediatric endocrinologists, so this protocol may improve detection of hypothyroidism in premature infants.

241 Hypoglycemia unawareness and co-occurrence of thyroid autoimmunity as features to help distinguish between type 1 and type 2 diabetes in an adult patient

SM Ford*

DM Borne

AM McClean

LS Engel

GL Cosentino

LSU Health Sciences Center, New Orleans, LA

Case Report

Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) can share many features, including presenting symptoms polydipsia, polyuria, and polyphagia as well as lab abnormalities of hyperglycemia and ketosis. However, care to make the correct diagnosis can make an important impact on patient outcomes, ease of medication administration, and limit dangerous adverse events such as hypoglycemia.

Case

A 49 year-old man with history of T2DM (diagnosed at age 31) and acquired hypothyroidism s/p neck irradiation to treat T-cell lymphoma endorsed episodes of tremors and sweating over the previous three months. During these episodes his blood sugar ranged between 40–60 mg/dL. For management of presumed T2DM, he was on a regimen of insulin glargine 30 units nightly. Chart review indicated that the patient previously tested positive for insulin antibodies. The clinical significance of the positive insulin antibodies was unclear given that the patient had been on insulin regimens for several years and may have generated an antibody response to insulin. Further testing revealed that Anti-GAD antibodies were > 250 IU/mL (normal range 0–5 IU/mL), confirming diagnosis of T1DM. Furthermore, his anti-thyroid peroxidase (TPO) antibody level was found to be elevated at 88.8 IU/mL (normal <9.0 IU/mL), confirming diagnosis of Hashimoto’s thyroiditis.

Discussion

T1DM occurs due to autoimmune destruction of the pancreatic islet cells, resulting in absolute insulin deficiency and subsequent hyperglycemia due to decreased endogenous insulin production. T2DM occurs due to impaired peripheral insulin responsiveness of insulin-sensitive tissues including skeletal muscle, adipose tissue, and liver, resulting in hyperglycemia due to inability of insulin to act at these tissues. Unlike T2DM, insulin sensitization of peripheral tissues is relatively preserved in T1DM, which leaves these patients more prone to experiencing frequent and/or severe hypoglycemic episodes. Practitioners should be especially suspicious of a missed diagnosis of T1DM in a thin patient with preserved insulin sensitivity and especially in any patients with other autoimmune conditions, thyroid disease being the most common.

242 Surgically treated resistant hypertension due to bilateral adrenal hyperplasia

K Ganesan*

AS Sallar

D James

University of Tennessee Health science center, Memphis, TN

Background

Treatment resistant hypertension (TRH) may affect about 15% of patients with hypertension. While primary hyperaldosteronism is a known etiology of TRH, clinicians must consider the possibility of elevations of other adrenal hormones. Early identification of an etiology may prevent or delay the onset of complications.

Case Report

Endocrinology was consulted on a 46 years-old man for evaluation of TRH. His past medical history is significant for TRH, congestive heart failure (Ejection Fraction 45–50%), and chronic kidney disease. Physical examination was unremarkable except for a blood pressure of 193/124 mmHg while on furosemide, isosorbide mononitrate, hydralazine, carvedilol, spironolactone, and clonidine. Chart review revealed mild hypokalemia. Computed tomography of the abdomen without contrast showed bilateral enlarged nodular adrenal glands with an increase in size over the last three years (left adrenal gland: 6.3 cm, right adrenal gland: 5.6 cm). Initial workup showed normal free plasma metanephrine, normetanephrine, aldosterone renin ratio, 17-hydroxyprogesterone, and undetectable random adrenocorticotropic hormone (ACTH) with random cortisol of 29 mcg/dl. Subsequent evaluation revealed elevated deoxycorticosterone (3030 ng/dL), 11-deoxycorticosterone (42 ng/d) and 18-Hydroxycorticosterone (640 ng/dL). He subsequently developed Cushing’s syndrome and diabetes mellitus.

The patient underwent laparoscopic left adrenalectomy and subtotal right adrenalectomy. Pathology showed macro-nodular adrenal cortical hyperplasia. He was started on hydrocortisone for postoperative adrenal insufficiency. On his most recent follow-up, his blood pressure was well controlled on bumetanide, carvedilol, metolazone, and nifedipine. (Hydralazine, isosorbide mononitrate, spironolactone, and clonidine were stopped). After surgery, Corticosterone (92.10 ng/dL), 11-Deoxycorticosterone (<5.00 ng/dL) and ACTH (9 pg/mL) normalized.

Conclusion

Determining the etiology of TRH should not be stopped after ruling out the ‘usual suspects’ since malignant hypertension with end-organ dysfunction can develop, if not appropriately treated. In our patient, TRH was due to elevated 18-Hydroxycorticosterone (precursor of aldosterone), which improved after adrenalectomy.

243 Prolonged infant hypoglycemia

I Jacks*

R Bassali

Augusta University, Augusta, GA

Case Report

8 week old male presents with persistent hypoglycemia. He went to his pediatrician’s office where his glucose was found to be 28 mg/dL, he was then transferred to the hospital. Prior to the current episode he had no fever, cough, congestion, emesis, diarrhea, or other symptoms. He had two prior hospitalizations for hypoglycemia at an outside facility with no cause found. During prior stays he required dextrose fluids at a glucose infusion rate of 5.6 mg/kg/min then was discharged with strict oral feedings every 3 hours. He was born at 38.6 weeks via spontaneous vaginal delivery. Patient‘s mother was induced due to preeclampsia. Birth was complicated by broken clavicle and he had prolonged hospital stay for hyperbilirubinemia. Family history was negative for any endocrine or metabolic disorders. Upon arrival to the hospital patient was noted to be well appearing with mild jaundice but otherwise unremarkable physical exam. Glucose on arrival was 50 mg/dL, prior to the next feed the glucose was noted to be 33, so critical hypoglycemia labs were collected. The infant was continued on PO feeding and started on D10 fluids while awaiting lab results. Labs were significant for direct bilirubin of 3.4 mg/dL, beta-hydroxybutyrate of <0.1 mmol/L, insulin level of <0.5 mcIU/mL, cortisol of 0.63 mcg/dL, and growth hormone of 0.55 ng/mL. Interpretation of the labs revealed an appropriately low insulin level, inappropriatley low cortisol, and low growth hormone. An ACTH stimulation test showed an inappropriate response to stimulation as the cortisol did not rise above 18 mcg/dL. Based on the lab results a diagnosis of panhypopituitarism induced adrenal insufficiency leading to hypoglycemia was made. After the diagnosis was made he was started on somatropin, levothyroxine, and prednisolone for hormone replacement. His dextrose fluids were then weaned off. Neuroimaging and ophthalmology consult to evaluate for associated septo-optic dysplasia was deferred to outpatient setting. Neonatal hypoglycemia is a relatively common condition with a wide variety of potential causes. A thorough workup including lab results collected during the hypoglycemic episodes are crucial to obtaining the correct diagnosis. Hypopituitarism leading to adrenal insufficiency and hypoglycemia is a rare cause of neonatal hypoglycemia but is important to recognize early for proper hormone replacement therapy.

244 Déjà vu: recurrent abdominal mass and new paraspinal mass in a young adult

M Lago*

H Chachere

J Sansone

H Elaasar

J Taylor

R Gomez

C Straatman

Louisiana State University School of Medicine in New Orleans, New Orleans, LA

Case Report

Neuroendocrine tumors are an uncommon source of pediatric hypertension, but should be considered in cases of adrenergic storming. Pheochromocytomas (PCC) account for 1% of pediatric HTN diagnoses and are more likely to be related to genetic mutations at younger ages of presentation. Multiple genetic syndromes predispose patients to develop PCC, including VHL, MEN-2, NF-1, and FPS (Familial Paraganglioma Syndromes).

A 20-year-old female presented with four days of chest and abdominal pain, palpitations, urinary frequency, diarrhea, dizziness, blurry vision, and headaches. Her history was significant for a left suprarenal PCC, resected at age 12. Vitals were notable for labile hypertension. Labs were normal except for mild anemia. CT of the chest and abdomen revealed a 5.9 × 4.5 × 5.1 cm paraspinal posterior mediastinal mass at T5-T8 and a 3.8 × 5.4 × 4.5 cm left-sided suprarenal mass.

Maternal history was notable for PCC and subsequent paraganglioma. Consequently, genetic testing at the patient’s initial presentation revealed an SDHB p.R46X mutation. Due to risk of tumor recurrence with SDHB mutations, frequent surveillance with serologic testing and imaging is recommended, but this patient was lost to follow up.

Ultimately, the addition of an α-blocker, β-blocker, and CCB were required to control hyperadrenergic symptoms. NET labs showed elevated plasma epinephrine, dopamine, and chromogranin A. MIBG revealed intense radiouptake of the paraspinal mass and no uptake of the suprarenal mass, similar to the prior PCC. Due to concern for PCC recurrence, biopsy was contraindicated, but resection has been planned.

Several SDH gene mutations have been associated with FPS. SDHB mutations are autosomal dominant, associated with the development of extra-adrenal tumors with an increased risk of malignancy. This case demonstrates the importance of genetic testing and long-term surveillance in pediatric patients with PCC.

245 Myonectin is a marker of remission of type 2 diabetes in obese human subjects

D Lawson*

F Stentz

University of Tennessee Health Science Center, Memphis, TN

Purpose of Study

Obesity is a national epidemic and is a major component of metabolic syndrome. To prevent the progression to Type 2 Diabetes (T2D), patients are instructed to either lose weight or are put on a medication regimen. To date, diet and exercise are considered the gold standard in prevention and treatment, however no single diet has emerged as the optimal diet for remission in T2D patients.

We studied the effect of a High Protein(HP)(30% protein, 40% carbohydrate, 30% fat) diet vs High Carbohydrate(HC)(15% protein, 55% carbohydrate, 30% fat) diet in obese, T2D patients on remission of T2D to normal glucose tolerance(NGT), weight loss, body composition, and metabolic parameters in this randomized controlled clinical trial.

Methods Used

We recruited 24 women and men who were recently diagnosed with T2DM and they were randomized to a HP or HC for 6 months. All food was provided and designed for weight loss according to participants resting metabolic rate. Oral glucose tolerance (OGTT), weight loss, insulin sensitivity(IS), metabolic parameters, cardiovascular risk factors (blood pressure, lipids), inflammatory markers and DXA (to determine Lean Mass (LM) and Fat Mass (FM)) were measured at Baseline (Bl) and after 6 months on the diets. The novel myokine, myonectin, was of interest due to the possible implications of its use in clinical practice and measured at Bl and 6 months.

Summary of Results

12 patients completed the study. 100% (n=6) of the HP group had remission to NGT. 16.5% (n=6) of the HC group had remission to NGT. Although similar weight loss was obtained LM was gained in the HP group (+2.30%), but was lost in the HC group (-2.09%) along with FM loss in both groups. OGTT studies showed significant improvement in IS to NGT in the HP group compared to the HC group.The HP diet group had greater improvements in CVR and inflammatory markers than the HC diet group. Myonectin levels were significantly lower after 6 months on the HP group compared to the HC group.

Conclusions

These data suggest that a diet with a high protein content is optimal to the remission of T2DM. This could be explained by the gain or preservation of lean body mass in patients. The changes in myonectin levels could be used as a marker of remission of T2D.

246 The rate of detection of congenital hypothyroidism in patients with congenital heart disease via newborn screen

S Mahajan*

A Shah

TO Findley

The University of Texas Health Science Center at Houston John P and Katherine G MGovern Medical School, New Braunfels, TX

Purpose of Study

Congenital hypothyroidism (CH) is the most common and preventable cause of intellectual disability in children, with a reported incidence of 1:2000–4000 in the general population. All newborns are screened for CH by newborn screening programs. Congenital heart defects (CHD) are the most common birth defect and may be associated with an increased risk for CH due to a common embryonic development pathway. We report a case series (n=12) of neonatal CHD treated for hypothyroidism and describe the rate of detection by newborn screening among CHD patients.

Methods Used

A single-center, retrospective review was conducted to identify CHD patients hospitalized in the neonatal intensive care unit (NICU) from January 2013 to March 2019 (n=413). Infants born before 32 weeks gestational age were excluded due to increased rates of hypothyroidism related to prematurity. Data collected included type of cardiac defect, birth parameters, newborn screen results, and duration of medical treatment for hypothyroidism with levothyroxine.

Summary of Results

Twelve patients were treated with levothyroxine during their hospitalization. Incidence of treatment for hypothyroidism among hospitalized CHD neonates was 1:34. The mean gestational age was 35 5/6 weeks and mean birth weight was 2408 g. Seven infants (58%) had a normal first newborn screening and five infants (42%) had a normal second newborn screening. The median age of initiation of levothyroxine was 41.5 (27 to 146) days of life. The incidence of permanent CH diagnosed at 3 years of age was 1:138 (n=3), one of which had Trisomy 21. Eight patients were lost to follow-up.

Conclusions

This case series demonstrates a higher rate of treatment of hypothyroidism in the neonatal period as well as permanent CH in CHD patients compared to the general population. The first and second newborn screens only accurately detected about half of patients who were required treatment with levothyroxine, suggesting the newborn screen may be an insufficient screen of CH for infants with CHD, making early identification of CH challenging in a high-risk population.

247 The cardiometabolic profile of a lean model of polycystic ovary syndrome

S McClung1*

JG Morato1

ED Torres Fernandez2

S Everman1

J Pruett1

D Romero1,3

L Cardozo Yane1,3

1University of Mississippi Medical Center, Jackson, MS

2The University of Texas at Austin, Dell Medical School, Austin, TX

3Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic Ovary Syndrome (PCOS) is the most common endocrinopathy in reproductive-age women. It is characterized by hyperandrogenemia and is associated with cardiometabolic abnormalities such as obesity, insulin resistance (IR), and increased blood pressure (BP). Obesity plays a major role in the clinical manifestations of PCOS, since weight loss is associated with reductions in metabolic derangements. Whether or not increased circulating androgens cause obesity and how these effects may occur remains poorly understood. We tested the hypothesis that obesity mediates the androgen-induced cardiometabolic abnormalities in PCOS.

Methods Used

Four-week-old female Sprague Dawley rats were randomized to either dihydrotestosterone (DHT, 7.5 mg/ 90 days) or control. DHT rats were assigned to ad libitum diet or daily pair-feeding schedule (PF-DHT) based on food intake (FI) of control (n=5–8 per group). Body composition (by EchoMRI), proteinuria, and IR were determined every 4 weeks. BP was measured by radiotelemetry.

Summary of Results

DHT rats have increased FI, body weight (BW), fat mass, proteinuria, IR, and BP than control. With pair-feeding, FI in PF-DHT was decreased to the same level as control. In PCOS, pair-feeding abolished the increase in fat mass (12.5 ± 1.7 vs 22 ± 2.5 g, p<0.001) and attenuated the increase in BW (269 ± 6 vs 308 ± 7 g, p<0.001). Pair-feeding normalized BP (103.8 ± 0.6 vs 109.6 ± 0.7 mmHg, p<0.0001) and ameliorated the androgen-induced increase in proteinuria. Pair-feeding worsened the Homeostatic Model Assessment of IR (5.4 ± 0.4 vs 3.4 ± 0.6, p<0.01).

Conclusions

In summary, pair feeding in PCOS decreases obesity which leads to a decrease in proteinuria and BP. Obesity appears to play a key role mediating the cardiometabolic derangements in women with PCOS. Though IR was not improved, weight loss is a promising therapeutic for the cardiometabolic abnormalities in PCOS. Funded by COBRE/MS CEPR P20GM121334.

248 Unusual adverse effect of commonly use antidiabetic agent

N Mon*

M Khan

RI Hazam

T Vo

Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX

Introduction

Euglycemic diabetic ketoacidosis (euDKA) due to sodium-glucose cotransporter 2 inhibitor (SGLT2 inhibitor) is a serious side effect that can be triggered by a very low carbohydrate diet with <1% incidence. It is vital to keep low threshold for diagnosis of euDKA in patients taking SGLT2 inhibitors to avoid delay management and to identify risk factors. We report a case of euDKA due to dapagliflozin with recent start of a very low carb diet.

Case

A 38 years old lady with type 2 diabetes mellitus, on Dapagliflozin for a year, presented to ED with 3 days of abdominal discomfort associated with intractable nausea and vomiting. She drank 6 packs of beer daily and started a very low carb diet 2 weeks ago. Admission vital signs and physical exam were unremarkable except mild epigastric tenderness. Labs: neutrophilic leukocytosis, glucose 185, HCO3 4, anion gap 20, BUN 8, creatinine 0.7, HbA1c 11.8; ABG pH 7, pCO2 8.6, HCO3 2, beta hydroxybutyrate 49 mg/dl, Lactic acid 0.8 and negative ethanol level. UA showed glucose3+,protein1+,ketone2+ & negative hCG. Once diagnosis of severe euDKA was confirmed, DKA protocol was initiated. She improved clinically and was discharged home with basal bolus insulin, discontinuation of dapagliflozin & diabetic education.

Discussion

Adverse effects of SGLT2 inhibitor should be considered in the presence of precipitants including strenuous physical activity, very low carbs/ketogenic diet, prolong starvation and heavy alcohol intake. It is contraindicated in eGFR<30. The mechanism of euDKA due to SGLT2 inhibitor is thought to be due to reduced insulin and increased glucagon secretion, which cause glucose metabolism shifting to fatty acid oxidation, leading to ketonemia and euDKA. By lowering the renal glucose excretion threshold, SGLT-2 inhibition may mimic starvation condition, leading to increased ketone and its renal re-absorption. It renders the body susceptible to ketonemia and continues to produce glycosuria, thereby causing euglycemia.

Conclusion

Early recognition of etiology of euDKA and precipitants are crucial to prevent metabolic consequences. Patients on SGLT2 inhibitor should be educated on signs and symptoms of DKA, precipitants and instructed to seek help when they are experiencing the symptoms.

249 Sarcoidosis presenting as hypoadrenalism

F Mubeen*

A Kamat

S Usala

Texas Tech University Health Sciences Center, Amarillo, TX

Case Report

Sarcoidosis is a multisystem granulomatous disorder that may present with lymphadenopathy, lung nodules, skin, joint and or eye lesions. Lung involvement is common but 30% may have extra-thoracic manifestations such as pituitary granulomas causing secondary adrenal insufficiency, but rarely presents as disease of the adrenal gland.

A 38-year-old athletic male was referred to endocrinology for possible hypoadrenalism. He had a past history of seasonal allergies, and had been recently seen by neurology for gradual onset of generalized muscle soreness, weakness and difficulty getting out of a chair. MRI of his brain was normal. He was nauseous and lightheaded on standing. In addition he had arthralgias. His father had sarcoidosis. Body mass index was 22.3 kg/m2. On examination he did not have periorbital edema, conjunctival injection, exophthalmos, visual field defects or cushingoid features. He had a palpable, mobile, supraclavicular lymph node. A 250 mcg cosyntropin test was interpreted as possibly in the hypoadrenal range with 30 and 60 min cortisol level of 19.9 mcg/dl and 22.5 mcg/dl, respectively. Serum protein immunoelectrophoresis revealed high IgG Kappa. His CBC, ESR, comprehensive metabolic profile, vitamin D, B12, free T4 and TSH were normal. Lymphoma and sarcoidosis were in the differential diagnosis with concomitant hypoadrenalism. He was started on hydrocortisone 20 mg/day and at 2 weeks follow-up he had significant clinical improvement. Hematology, rheumatology, and surgery were consulted with the following results: C-reactive protein 32 elevated, Anti-CCP 0.6, Rheumatoid factor 15, Angiotensin converting enzyme 102 elevated, peripheral blood smear bone marrow were normal. Lymph node biopsy was negative for lymphoma or granulomas. CT scan of chest, abdomen, and pelvis was normal. Diagnosis of sarcoidosis was made, and the patient was started on hydroxychloroquine. A repeat 250 mcg cosyntropin test at 18 months was definitively in the hypoadrenal range, 10.0 mcg/dl and 11.6 mcg/dl.

Autoimmune endocrinopathies frequently coexist with sarcoidosis, and when Addison’s disease occurs in this context, the mechanism is usually autoimmune adrenalitis. Our patient did not have a tissue diagnosis of noncaseating granulomas, but the lymphadenopathy and elevated ACE levels made the diagnosis of sarcoidosis likely.

250 Hungry bone syndrome following parathyroidectomy in tertiary hyperparathyroidism

M Oye*

D Gidla

S Paglialonga

MB Omar

P Reddy

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 51-year-old diabetic man with end stage renal disease on hemodialysis was admitted for total parathyroidectomy with autotransplantation. He had been on dialysis for the prior 16 years and developed secondary hyperparathyroidism 7 years ago, followed by tertiary hyperparathyroidism 7 months ago with a markedly higher parathyroid hormone (PTH) level. His asymptomatic hypercalcemia of approximately 11 mg/dL and average PTH of 2000 pg/ml had been refractory to medical therapy, thus parathyroidectomy was pursued. On day 1 postoperatively he developed diffuse paresthesias with Chovstek’s sign and a prolonged QTc on electrocardiogram. Investigations revealed a profound hypocalcemia and hypophosphatemia with a precipitous fall in PTH to 32 pg/ml. Over the ensuing week he required aggressive parenteral and oral calcium and vitamin D supplementation. He was discharged on substantial doses of oral supplementation and despite compliance, had to be readmitted 3 weeks later for symptomatic hypocalcemia. Parenteral calcium loading at dialysis sessions with high calcium baths are being planned.

Discussion

Hungry bone syndrome is the phenomenon of hyperdynamic bony reabsorption of calcium after parathyroidectomy. Although initially described with primary hyperparathyroidism (HPT), it has been shown to be more common and severe in HPT secondary to renal disease. In such cases, profound hypocalcemia, hypophosphatemia and hypomagnesemia are typical. Hyperkalemia may also be seen although the mechanism is yet uncertain. In this case of tertiary HPT, autotransplantation was performed in attempt to reduce the risk of postoperative hungry bone syndrome, although, it was unsuccessful as demonstrated. Preoperative calcium and calcitriol supplementation have been purported to reduce the risk of hungry bone syndrome and aggressive repletion is the mainstay of postoperative management. However, despite the prevalence of end stage renal disease, there is still a paucity of high quality data on effective prevention or management of this disease.

251 Hyperinsulinemic hypoglycemia in an infant with partial trisomy 13

A Pandhi*

M Drawdy

C Antonetti

Ascension Sacred Heart Hospital Pensacola, Pensacola, FL

Case Report

Hyperinsulinemic hypoglycemia is unregulated secretion of insulin from the pancreas in the presence of hypoglycemia. Hyperinsulinemia has been reported in patients with chromosomal abnormalities including Beckwith-Wiedemann and Turner syndromes, but rarely reported in trisomy 13. We present a case of an 8-week-old former 37 week male with a translocation of chromosome 13:17 admitted with feeding difficulty and apnea. History is significant for a brief NICU stay for hypoglycemia managed with orogastric feeds. No further evaluation for hypoglycemia was done at that time. On presentation, vital signs were normal for age. He was well-appearing with low-set ears and retrognathia. No clefts, no microphallus, or midline defects noted. He had normal muscle bulk and tone, no nystagmus, and present infant reflexes. Initial blood glucose level was 48 mg/dl. He was started on D5 containing IV fluids. Several hours later he developed hypoxia and seizure-like activity. Blood glucose level was 43 mg/dl, with an elevated insulin of 30.7 IU/mL, beta-hydroxybutarate 0.27 mmol/L, cortisol 12.77 mcg/dL, and growth hormone 1.84 ng/ml. He received three D10 fluid boluses which would transiently improve blood glucose before hypoglycemia recurred. He was diagnosed with hyperinsulinemic hypoglycemia, managed with continuous nasogastric feeds and diazoxide. Blood glucose levels normalized. He developed peripheral edema, a side effect of diazoxide, managed with furosemide. The diazoxide dose was weaned as an outpatient and blood glucoses have remained stable with bolus feeds. Hyperinsulinemic hypoglycemia is caused by inappropriate insulin secretion from pancreatic beta-cells, and can worsen with high dextrose concentration boluses, as the resulting hyperglycemia triggers more insulin secretion. The mechanism for inappropriate insulin secretion in patients with chromosomal abnormalities remains unknown, though several genes have been identified that may be involved. Hyperinsulinemic hypoglycemia could be considered in patients with chromosomal abnormalities and recurrent hypoglycemia, as it is managed with continuous glucose infusion rather than high concentration dextrose boluses.

252 Propylthiouracil induced hepatotoxicity

N Pant*

University of Tennessee, Memphis, TN

Introduction

Propylthiouracil (PTU) is one of the common antithyroid drugs used in treatment of hyperthyroidism. Common side effects includes rash, arthralgia, vasculitis, and agranulocytosis. Hepatotoxicity is a rare side effect of PTU therapy. We present an interesting case of PTU induced hepatotoxicity.

Case Description

A 39 year old AAM with history of Grave’s disease presented to hospital with complaint of weakness and fatigue. Vital signs were within normal limits. He was alert and oriented initially, but became more altered and was subsequently intubated to protect airway. His laboratory results showed TSH of 0.00 mIU/mL and Free T4 of 3.31 ng/dL. He was started on hydrocortisone, propranolol, Lugol’s iodine, and PTU. He had markedly elevated liver function test (LFTs) on day two of hospitalization [AST 3720 Units/L, ALT 2433 Units/L, ALP 139 Units/L and Total bilirubin of 2.8 mg/dL]. PTU was discontinued. His LFTs gradually improved off PTU, so he was started on methimazole. He progressively continued to improve. He was extubated to nasal cannula and was eventually discharged on Methimazole and Propanolol.

Discussion

Graves’ disease is the most common cause of hyperthyroidism in the United States. Treatment options include antithyroid drugs, radioactive iodine treatment and surgery. Drug induced liver injury has been reported in 0.03% to 0.5% of patients taking antithyroid drugs. Propylthiouracil is a thioamide and a thyroid hormone antagonist which acts by inhibiting the incorporation of iodine into tyrosyl residues of thyroglobulin and thus lowering thyroid hormone levels. Hepatotoxicity is a rare complication of thioamide therapy. The onset of hepatotoxicity is usually within 2 to 12 weeks of starting, and the pattern of enzyme elevations is typically hepatocellular. The severity of PTU induced liver injury varies from mild, transient serum aminotransferase elevations to severe hepatitis, hepatic failure, need for liver transplantation and even death. After medication discontinuation, liver function tests should be monitored weekly until normalization.

Conclusion

Although PTU-induced liver failure is rare in clinical practice, liver function should be appropriately monitored during treatment with PTU, especially in the first 6 months of therapy.

253 Hyperglycemic hyperosmoloar state: when SARS-CoV 2 turns down to be sweet

I Rivera-Nazario*

JL Ayala Rivera

A Nieves-Ortiz

K Hernandez Moya

MT Torres Torres

M Delgado

N Roman-Velez

HR Cintrón-Colón

Hospital Municipio de San Juan, Trujillo Alto, Puerto Rico

Case Report

Hyperglycemic emergencies such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) are commonly precipitated by infections. Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) is a Novel infectious process triggering hyperglycemic crisis. SARS-CoV-2 at the level of the lungs affect ACE2 functioning which in turns decrease the B cells proliferation at the pancreas and impede insulin secretion.

We present a 39-year-old woman with comorbidities of uterine fibroma, who presented with a complaint of general malaise, polyuria and polydipsia of 1 week of evolution. Associated with sore throat, subjective fever, dry cough, abdominal pain, nausea and vomiting. Physical examination remarkable for dry oral mucosa, decreased skin turgor, and prolonged capillary refills. Vital signs significant for hypertension, tachycardia and tachypnea. Laboratory work up remarkable for glucose of 1321 mg/dL, HCO3- of 16 mEq/L, serum osmolality of 333 mOsm/kg, serum ketones positive and HbA1C of 15%. ABG’s showed pH of 7.33, PCO2 of 29.8 and a PAO2 of 158.5 mmHg for a high anion gap metabolic acidosis, non-anion gap metabolic acidosis with respiratory alkalosis. Chest X-ray revealed bilateral perihilar, peribronchial cuffing. We get back positive PCR for SARS-CoV-2. Clinical and laboratory workup met criteria for the diagnosis of HHS and Diabetes Mellitus de Novo precipitated by SARS-CoV-2 infection. Patient was treated with IV fluids and insulin infusion with resolution of hyperglycemia, ketonemia and symptoms.

SARS-CoV-2 infection can precipitate acute metabolic complications in patients with diabetes or unknown diagnosis of diabetes. The effect of the virus could be direct on β-cell function and patient can develop DKA or HHS. To our knowledge, there are only a few cases reported of HHS precipitated by SARS-CoV-2 infection therefore medical awareness is important for early diagnosis, management and treatment in patients presenting with hyperglycemic emergencies de novo since SARS-CoV-2 infection must be ruled out.

254 The effect of metformin use on prevalence of varicose veins in the type 2 diabetic hispanic population- a retrospective study

FD Saenz1,2*

F Dihowm1,2

1Texas Tech University Health Sciences Center El Paso, El Paso, TX

2Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX

Purpose of Study

Several studies have been able to demonstrate that Metformin may reduce risk of cardiovascular disease in type 2 diabetes. This study focuses on verifying such association in the Hispanic population, who are adversely affected by type 2 diabetes. The aim of this retrospective cohort study is to analyze and confirm if there is reduced risk of varicose veins with Metformin use in the type 2 diabetic Hispanic population.

Methods Used

This comparative, retrospective chart review analysis, reviews 1765 patient medical charts. Patients who matched our inclusion criteria: type 2 diabetes, seen between 2008–2018, and above 18 years of age. Data was divided into various medication groups centered around Metformin to compare prevalence of varicose vein. All analyses were carried out using STATA V.15.

Summary of Results

The prevalence of varicose veins was high in the Metformin group 40 (3.1%) compared with other medications group 9 (1.9%) with P value of 0.19. The unadjusted association results demonstrated an increased risk of having varicose veins within the Metformin user population PR (95%) 1.6 (0.78, 3.28),yet the results between both groups did not have a significant P value (0.20) to confirm this finding. Unadjusted associations to increased risk of varicose veins with significant results were found in variables including age, hypertension, dyslipidemia, and statin use with P value of <0.001, 0.048, 0.029, and 0.026, respectively. Adjusted association in Metformin use found increased prevalence in varicose veins PR 1.25 (0.6, 2.6), but P value was 0.555. Metformin group was compared with 3 other groups (insulin group, sulfonylurea group and other hypoglycemic agents like sulfonyureas, meglitinides, acarbose, and thiazolidinedione), the results demonstrated an increased risk of having varicose veins within the Metformin group with PR 1.61, 1.18, 1.47 respectively, but it was not statistically significant.

Conclusions

The importance of these results is that Metformin may not have a protective effect against varicose veins in the Hispanic population. A more detailed and controlled study with individuals taking Metformin may need to be performed.

255 Dynamic course of normal TSH function after excision of a thyrotropin-secreting pituitary tumor (TSHoma) in a patient with thyroid cancer: review of the literature

G Sindi*

S Usala

Texas Tech University Health Science Center, Amarillo, TX

Case Report

Thyrotropin-secreting adenomas (TSHomas) are a relatively rare pituitary tumor and consequently there is limited information on both the time course of normal thyrotroph function after surgical cure and its association with thyroid cancer. A 53-old-man was incidentally found to have an inappropriately elevated TSH with biochemical hyperthyroidism during the evaluation of a goiter. He felt well and displayed only a mild finger tremor. His pre-treatment TSH was 6.43±0.78 (SE) uIU/ml (95%CI: 3.93, 8.94) (ref: 0.40 - 4.00 uIU/ml), Free Thyroxine 2.64±0.12(SE) ng/dl (95%CI:2.0, 3.2) (ref: 0.80 - 1.90 ng/dl), and Free Triiodothyronine 6.29±0.27(SE) pg/ml (95%CI:5.11, 7.48) (ref: 1.80 - 4.20 pg/ml). A thyroid ultrasound demonstrated multinodular goiter and a 5.1 cm dominant nodule revealed a follicular neoplasm by cytology with Afirma FNA thyroid analysis interpreted as suspicious for thyroid cancer. An MRI pituitary study showed a 1.0 cm x 0.9 cm x 0.8 cm pituitary tumor. Transsphenoidal adenomectomy was first performed with prompt reduction in TSH and subsequent hypothyroidism. The pre- operative TSH of 8.5 mIU/ml fell to 0.13 mIU/ml and 0.01 mIU/ml, two and six days post-excision, respectively. The TSH was still undetectable 27 days post- excision, but within normal limits at 0.6 mIU/ml 45 days post-excision. There was resolution of sleeplessness and tremor post adenomectomy. A thyroidectomy for thyroid cancer was performed 34 days after the transsphenoidal surgery and a 1.1 cm differentiated papillary thyroid cancer was found within the left dominant adenomatoid nodule with bilateral multi-foci of 0.8 cm and 0.3 cm papillary cancer. The TSH remained within normal limits for 14 months after TSHoma excision while the patient was on Levothyroxine replacement, until the Levothyroxine dose was increased for partial TSH suppression to treat the history of thyroid cancer. The serum Thyroglobulin was undetectable and the patient was negative for Thyroglobulin antibodies. In conclusion, normal TSH function was established within seven weeks of TSHoma excision with a subsequent thyroidectomy for multi-focal thyroid cancer.

256 Alterations in classical and non-classical intrarenal renin angiotensin system in polycystic ovary syndrome

SA Ye1*

S Everman1

ED Torres Fernandez2

J Pruett1

D Romero1,3

L Yanes Cardozo1,3

1University of Mississippi Medical Center, Jackson, MS

2The University of Texas at Austin, Austin, TX

3Women’s Health Research Center, Jackson, MS

Purpose of Study

Polycystic Ovary Syndrome (PCOS), the most common endocrinopathy in women, is characterized by androgen-excess, associated with obesity and hypertension (HTN). Therapeutic options to treat PCOS-associated cardiovascular risk factors are limited. We have previously characterized a rat model of PCOS in which chronic androgen-excess causes increased body weight, HTN, and activation of angiotensin converting enzyme/angiotensin 2 receptor type 1 (ACE/AT1R) axis of intrarenal Renin Angiotensin System (RAS) components. Still, the mechanisms responsible for HTN in PCOS remain unclear. In this study, we tested how chronic androgen-excess changes the renal mRNA expression profile of the RAS in a model of PCOS.

Methods Used

Four-week old female SD rats were randomized to either control or dihydrotestoterone (7.5 mg/90 days). BP was measured by radiotelemtry. After 85 days of DHT, renal cortices and medullas were collected. Renal mRNA expression was assessed separately by RT-qPCR.

Summary of Results

DHT rats were found to be hypertensive (116±1 vs 107±2 mmHg, p<0.001). In DHT rats, cortical mRNA expression of angiotensinogen, AT1R, renin receptor, dipeptidyl peptidase 3 (DPP3), neprilysin (MME), neurolysin (NLN), and prolylendopeptidase (PREP) were increased. In addition, medullary mRNA expression of ACE (4.89±1.12 vs 0.88±0.293 AU, p<0.01), ACE2 (3.00±0.78 vs 0.36±0.12 AU, p<0.05), angiotensinogen, AT1R, DPP3, kallikrein 1, MME, NLN, PREP, Mas 1 receptor (MAS) and thimet-oligopeptidase were increased. Medullary mRNA expression of renin and aminopeptidase B were decreased in DHT rats.

Conclusions

In summary, androgen-excess led to increase ACE/AT1R and ACE2/MAS axis components in both cortex and medulla. The increased ACE2/MAS axis could be a compensatory mechanism for the HTN in PCOS. This study highlights the effect of androgen-excess modulating the intrarenal RAS. Treatments focused on targeting RAS components may be promising therapeutic tools to ameliorate the cardiovascular abnormalities observed in PCOS. Funded by COBRE/MS P20 GM-121334.

Gastroenterology and nutrition and dietary supplements

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
257 Chronic diarrhea as a presentation of behcet disease

M Abohelwa1*

M Elmassry2

S Shahbandar1

J Abdelmalek1

E Elgwairi1

K Nugent1

1Texas Tech University Health Science Center, Lubbock, TX

2University of Leicester, Leicester, UK

Introduction

Behçet disease is a rare disease characterized by recurrent oral ulcers, genital ulcers, ocular disease, skin lesions, gastrointestinal involvement, vascular disease, and arthritis. The clinical symptoms are due to vasculitis.

Case presentation

A 32-year-old male patient presented for chronic diarrhea that has been present for four months. He described it as watery, occasionally bloody, 8–10 times a day associated with mucous. He reported 16 kg weight loss in 4 months, recurrent oral ulcers for a year, recurrent joint pains, and eye symptoms; he described right eye pain, redness, blurry vision, light sensitivity, and sometimes a skin rash. At the site of needle pricking for blood labs, he started to develop papule around it after 24 hours. CT abdomen showed thickening of the ileum and cecum. A colonoscopy was done to rule out inflammatory bowel disease (IBD); however, the biopsy showed focal ulceration, cryptitis, and crypt abscesses that were atypical for IBD. He was examined by an ophthalmologist, who documented evidence of uveitis in his right eye. The Rheumatology team was consulted and did a pathergy; it was positive after 48 hours. The patient met the criteria for the diagnosis of Behçet disease. The presence of recurrent large oral aphthae one year before presentation, evidence of uveitis, skin rash, and positive pathergy test confirmed the diagnosis. He was started on colchicine and reported improvement after three months of follow up.

Discussion

The diagnosis of Behçet disease is challenging. No pathognomonic test can be used for definitive diagnosis. The presence of recurrent oral aphthae at least three times in a year plus two of the following: recurrent genital aphthae, uveitis, skin lesions (pseudofolliculitis, papulopustular lesions, and erythema nodosum), and positive pathergy test defined by a papule of 2 mm or more developing after oblique insertion of a 20-gauge needle 5 mm into the skin of the forearm after 24–48 hours. Gastrointestinal involvement is rare and can be challenging to differentiate from inflammatory bowel disease. It causes ulceration, mostly in the terminal ileum, cecum, and the ascending colon like our patient.

258 Febrile neutropenia following infliximab

AA Ali*

B Bajric

J Calvert

P Reddy

University of Florida College of Medicine – Jacksonville, Jacksonville, FL

Case Report

A 24-year female with multisegment Crohn’s disease presented with fever, chills and myalgia. Six days prior to admission she received her first treatment dose of Infliximab. Admission CBC revealed a leukopenia 2.86 × 109. The patient was started on Zosyn and admitted for management of febrile neutropenia. An infectious work-up was non-revealing. Subsequent labs revealed worsening leucopenia with nadir 0.71 × 109 and an absolute neutrophil count of 0.15 × 103. The patient responded to treatment with Granulocyte Colony Stimulating Factor (Filgrastim). The patient defervesced and was discharged with a WCC 7.41 × 109 and absolute neutrophil count 4.75 × 103.

Agranulocytosis is a rarely documented side effect of Infliximab therapy likely due to the formation of autoantibodies against granulocytes and neutrophils. Infliximab is a chimeric monoclonal antibody that targets TNF-α, which leads to a disruption of the inflammatory cascade. On the other hand, as TNF-α may regulate interleukin (IL)-1, IL-6, IL-8 and granulocyte and monocyte CSF (GMCSF), its blockage by Infliximab may interfere with bone marrow-derived cell proliferation and maturation.

Drug induced neutropenia is a rare complication of Infliximab and is associated with a high rate of infectious complications and an increased mortality rate. Blood cell parameters both pre- and post- Infliximab infusion should be monitored particularly in the early stages following initiation of anti-TNF agents.

Abstract 258 Figure 1

White blood cell trend both pre- and post- infliximab infusion.

259 Uncommon case of achalasia in a patient with long standing dysphagia

FA Aponte Santos*

P Costas Caseres

I Padial Doble

Universidad de Puerto Rico Escuela de Medicina, Guaynabo, Puerto Rico

Case Report

Achalasia is characterized by lack of relaxation of the lower esophageal sphincter. The most common presenting symptom is dysphagia to solids and liquids. Since the disease is uncommon and patients may be able to compensate to early milder symptoms, the diagnosis may be delayed for years. We present a rare case of worsening dysphagia for more than a decade that highlights the importance of a high index suspicion and due diligence in the diagnosis and management of this disease.

71 years-old male presents to our institution with progressive esophageal dysphagia. The patient was initially referred in 2005 to a gastroenterologist due to dysphagia, chest pain, and regurgitation. At that time, imaging findings revealed a dilated esophagus. He was placed in PPI’s for symptomatic relief while workup was completed. Due to partial resolution of symptoms, the patient did not continue evaluation and was lost follow up. Fourteen years later, he presented to our institution with inability to ingest liquids or solids. Barium esophagogram brought from another institution showed the classic bird’s beak appearance of achalasia. Chest X-ray performed while in the ED showed severe widening of the mediastinum. Upper GI endoscopy was performed which demonstrated a long and tortuous esophagus. Subsequent high-resolution manometry showed absence of peristalsis and esophageal contractions with swallows. These findings were consistent with, but not diagnostic of, achalasia type 1 by Chicago classification v3.0 since the manometry catheter was unable to traverse the LES due to the altered esophageal anatomy. The diagnosis was made using radiological, clinical and available manometrical criteria. The patient underwent heller myotomy with partial anterior fundoplication with full resolution of the symptoms.

Achalasia is an uncommon disease with an annual incidence of 1.6 cases per 100,000 individuals. Given the rarity of the disease most primary care physicians will rarely encounter this disease in the daily practice. It is important to maintain a low threshold of suspicion in patients presenting with signs and symptoms of achalasia. Prompt identification and rapid treatment diminish the long term sequelae and potential complications. Finally improving outcomes and, more importantly, quality of life.

260 A case of recurrent pancreatitis secondary to pancreas divisum

HS Brar*

SJ Tang

UMMC, Flowood, MS

Case Report

Pancreas divisum is a common congenital anomaly of hepatobiliary system with an incidence of 5%-14%. It occurs due to failure of fusion of dorsal and ventral ducts of pancreas resulting in openings at abnormal positions causing pancreatitis. The diagnosis is challenging and if untreated can lead to pancreatic failure.

A 66 years old AAM with PMH of HTN, DM, CAD and recurrent pancreatitis presented with 4 days of epigastric pain. It was deep, aching without radiation and aggravated by food. He denied vomiting, diarrhea, fever or jaundice.

He had multiple admissions for similar complaints over last 4 years which were treated as acute pancreatitis. He reported anorexia and weight loss. He denied alcohol intake.

Physical exam revealed epigastric tenderness without any palpable mass.

Lab findings showed TLC 7300, T.bili 0.96, ALT 9, AST 10, ALP 82, lipase 47 and TG 71.

USG Abdomen showed cholelithiasis without cholecystitis or biliary dilatation. CT abdomen revealed interstitial edematous pancreatitis with peripancreatic fluid. MRI abdomen revealed pancreas divisum. The major pancreatic duct drained primarily into minor papilla but had a connection with minor pancreatic duct which emptied into major papilla.

ERCP confirmed major dorsal duct opening at minor papilla and minor duct opening at major papilla. He underwent minor papilla sphincterotomy with stent placement in dorsal pancreatic duct. He reported significant improvement and no recurrent episodes were reported.

Pancreatic divisum is a congenital anatomical anomaly characterized by the non-fusion of ventral and dorsal pancreas during fetal development. The major pancreatic duct(Wirsung) drains the majority of pancreas, and ends at major duodenal papilla(hepatopancreatic ampulla); the accessory pancreatic duct(Santorini) arises from head, crosses Wirsung’s duct and ends at minor duodenal papilla. In Pancreatic Divisum, the major pancreatic duct drains into the minor duodenal papilla and the accessory duct drains at the ampulla. This leads to insufficient drainage and symptoms of recurrent pancreatitis, bowel obstruction and even shock. CT abdomen is helpful but imaging of choice is cholangiography(ERCP or MRCP). The usual therapeutic solution is a sphincterotomy of the minor duodenal papilla, which decongests the duct. Some cases may need surgical sphincterotomy or even partial pancreatectomy.

261 A rare case of hepatocellular carcinoma with metastasis to the heart

HS Brar*

J Kang

H Daugherty

D Harkins

UMMC, Flowood, MS

Case Report

Hepatocellular carcinoma(HCC) is a common malignancy and the most frequent sites of metastasis include lungs, bone and brain. Intra-cardiac involvement rarely develops and has a poor prognosis. We discuss an unusual metastasis of HCC into the right atrium extending to the left atrium in patient with Hepatitis C.

A 66 year-old AAF with no known medical history, presented with epigastric pain for 1 week. She had decreased appetite and 10 lb weight loss in 2 months. She denied vomiting, melena, hematemesis, dysphagia, fever or cardiac symptoms like SOB, chest pain and orthopnea. The physical exam was unremarkable. Lab studies showed: WBC 12.6; Hb 12.5; Plt 155; ESR 76, PT 16; INR 1.4; total protein 8.6; albumin 3.0; AST 110; ALT 57; ALP 100; T.Bili 1.2 and direct 0.45. HepC Ab was positive. HepB sAg and Ab were negative. AFP: 227(N: 0–5.8). EKG was normal. CXR showed right lung nodule suggestive of metastasis. CT triple phase showed 7 cm heterogeneous liver mass concerning for HCC with extension to the IVC, SVC, right and left atrium along with non-calcified 11 × 19 mm pulmonary nodule. TTE showed 2.5 × 2.4 cm large mass in right atrium extending from IVC and abutting the atrial septum. TEE showed a well circumscribed mass protruding from IVC to right atrium and extending through atrial septum into left atrium through fossa ovalis. Patient was not deemed to be a surgical candidate and refused medical management considering the poor prognosis. 2 months later, she was diagnosed with COVID-19 and died of respiratory failure. No symptoms of CHF were present even at later stage.

Discussion

The prevalence of HCC is about 180 million worldwide with rising incidence. It is associated with poor prognosis with median survival of 4–7 months. The prognosis with cardiac involvement is worse with median survival of 1–4 months. The possible complications include HF, TR or TS, LVOT obstruction and SCD. The symptoms of dyspnea and edema are generally seen with cardiac involvement. The tumor invades IVC and reaches cardiac cavities. In spite of this, cardiac metastasis is still an unusual presentation of HCC. Our case is of a patient of HCC with intracardiac metastasis and with no cardiac symptoms. The case highlights that heart involvement should be suspected with HCC and screening TTE should be done even in absence of cardiac manifestations.

262 Cameron lesions: obscure gastrointestinal bleed presenting with iron deficiency anemia

HS Brar1*

B Ross2

P Hosseini-Carroll1

1UMMC, Flowood, MS

2GV Montgomery VAMC, Jackson, MS

Case Report

Cameron lesions are erosive ulcers of the gastric mucosa associated with large hiatal hernia. Lesions occur due to sliding of the hernia through diaphragm. The relevance of the lesions pertains to their potential as a source of chronic, occult GIB and iron deficiency anemia(IDA).

A 71-year-old man was referred for GI consultation due to history of refractory IDA. There was no history of acute GI bleed. He presented with a symptomatic microcytic, hypochromic anemia (Hb 8.4 mg/dL, Hct 28.4%) and low serum ferritin (2.2 ng/mL). He was taking PPI for acid reflux and oral FeSo4 with ascorbic acid to treat IDA. However, his CBC, transferrin saturation, and TIBC failed to stabilize despite iv iron. An extensive workup for a positive FOBT failed to reveal any pathology. EGD did not show esophagitis, gastritis, duodenitis, or a PUD, colonoscopy did not show mucosal inflammation, polyps or mass, diverticulosis, or angiodysplasia, and capsule endoscopy was unremarkable. He denied melena, hematochezia, or loose stools; Celiac disease labs were negative. Though treated for HTN, there was no ischemic or valvular heart disease, and only a systolic flow murmur was noted. A CXR to evaluate his dyspnea revealed a double density overlying heart at level of diaphragmatic hiatus; a subsequent CT scan showed a large hiatal hernia containing gastric fundus and portion of gastric body. EGD was repeated, which revealed multiple linear erosions(10–15 mm) of gastric folds consistent with Cameron lesions, which were believed to be the source of chronic GI bleed. Esophageal manometry and pH testing are being conducted, prior to definitive surgical intervention.

Cameron lesions are a rare cause of obscure UGIB that are localized to the gastric body in patients with large hiatal hernias. The pathogenesis is ischemia of the gastric folds due to trauma to the riding hiatal sac by the diaphragm causing slow blood loss and IDA. The lesions are often missed on initial EGD, multiple endoscopies are required for diagnosis. Management is medical or surgical, but rarely endoscopic. Medical therapy includes PPI and iron supplements. The surgical options are ulcerectomy or fundoplication. This case highlights considering Cameron lesions as a possible cause of obscure GI bleed presenting as chronic or recurrent IDA.

263 Plummer-vinson syndrome presenting as sudden onset dysphagia in a young black woman

HS Brar*

B Brousse

D Schaefer

UMMC, Flowood, MS

Introduction

Plummer-Vinson Syndrome (PVS) is a triad of iron deficiency anemia(IDA), esophageal webs and dysphagia. The prevalence is around 1 in 1,000,000. It is found in middle aged women between 40 to 50 years and is rare before 30. It usually presents with fatigue, SOB or dysphagia.

Case Report

A 21-year-old AAF presented with difficulty swallowing solid food. The symptoms progressed gradually where she could take only a soft diet. She denied nausea, vomiting, hematemesis, heartburn or dark color stools. She had a similar episode 2 years back diagnosed as pill esophagitis. Her medical history was significant for IDA due to menorrhagia. She denied any history of alcohol, smoking, or illicit drug use. She denied any medication use. She had no history of PUD or collagen tissue disorder. Her family history was unremarkable. At presentation, the physical exam was significant for pale conjunctiva and flow murmur. Lab results showed Hb of 5.5 g/dl, Hct of 23 and Mentzer index of 15. PBF showed hypochromic and microcytic cells. Serum iron was 3 μg/dl, ferritin 3 ng/mL, TIBC 394 μg/dl, and transferrin saturation of 3%. LFT and RFT were unremarkable (AST 21 IU/L, ALT 5 IU/L, BUN 7 mg/dl, and creatinine 0.44 mg/dl). CXR was normal with no acute abnormality. Barium Esophagogram demonstrated contrast pooling in the piriform sinuses with no passage into the esophagus. EGD showed 3 moderate to severe stenosis in the esophagus. The patient underwent blood transfusion and balloon dilatations over the guidewire to a dilatation of 7 mm. She was given iron supplementation. After 1 month, she underwent repeat dilatation to 10 mm. She had symptomatic relief and her Hb improved to 8.2 g/dl at 1-month follow up.

Plummer-Vinson Syndrome is a precancerous condition with high potential for malignancy. The pathogenesis is speculated to be due to iron-deficiency as there has been improvement with iron supplementation. The early management is crucial as these webs can progress to SCC. The case emphasizes the importance of evaluating patients with dysphagia and be cautious of red flag signs. It highlights that although PVS is uncommon before the age of 30 years, it should be considered in the differentials of dysphagia. Early diagnosis is important and prognosis is usually good with iron supplementation alone or in combination with mechanical dilatation.

264 Chronic diarrhea due to homozygous diacylglycerol O-acyltransferase 1 mutation

CI Chinchilla Putzeys*

N Amritphale

MR Roca Garcia

AM Ponnambalam

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

A 4-week-old female, born at 38 weeks presented with 1 kg weight loss, fussiness, fever, vomiting, and diarrhea. Her diarrhea started at birth with 6 to 8 greenish large volume stools per day. Diarrhea resolved when not fed. She was breastfed and supplemented with peptide-based formula. On examination, she had no dysmorphic features and was dehydrated.

Laboratory tests revealed metabolic acidosis, hyponatremia, hypoalbuminemia, and normal cholesterol. Stool alpha-1-antitrypsin was elevated, fecal PCR multiplex, fat, reducing substances were negative and fecal elastase was normal. Attempts to continue amino acid-based formula were unsuccessful and she was transitioned to parenteral nutrition.

Upper endoscopic biopsies showed partial duodenal villous atrophy, stains were negative for microvillus inclusions by electron microscopy. Whole exome sequencing was positive for diacylglycerol O-acyltransferase 1 (DGAT1) gene mutation, variant c.751+2T>C homozygous. Her symptoms were resolved with a 3% fat formula and a low-fat diet.

DGAT1 is an enzyme that helps to catalyze the formation of triglycerides from diacylglycerol and fatty acyl-CoA. This is the final committed step of triglyceride digestion before they are packaged into chylomicrons. Toxic accumulations of DGAT1 lipid substrates in the epithelium can lead to the destruction of the enterocyte. Intestinal biopsies in DGAT 1 deficiency showed dermal fibroblasts and intestinal organoids with altered lipid metabolism and have increased susceptibility to lipid-induced cell death.

There are five different types of DGAT1 gene mutations. These patients have severe congenital diarrhea and protein-losing enteropathy. There has been a difference in phenotype presentation for DGAT1 deficiency with different laboratory findings and outcomes for patients with the same mutation. The key intervention is the introduction of a fat-restricted diet which prevents the development of a full-blown protein-losing enteropathy.

This child did well on the low-fat formula with the resolution of diarrhea and protein-losing enteropathy.

DGAT1 deficiency is a rare disorder and whole exome gene sequencing helps in identifying it sooner so that appropriate management can be instituted.

265 The inflammatory bowel disease conundrum: establishing a definitive diagnosis in cases with overlapping features

CI Chinchilla Putzeys*

L Thai

D Gremse

University of South Alabama Children’s and Women’s Hospital, Mobile, AL

Case Report

The differentiation of Crohn’s disease (CD) from ulcerative colitis (UC) can be challenging and establishing an exact diagnosis is essential for correct treatment.

Our patient was diagnosed with inflammatory bowel disease (IBD) at 10 years old after a 4-month history of painful bloody diarrhea and 15 pounds weight loss. Investigations showed iron deficiency anemia, elevated ESR, CRP, and p-ANCA. Endoscopy showed pancolitis with superficial erosions, shallow ulcerations, and exudates. Biopsy showed proctitis, colitis, diffuse enteritis without granulomas. Duodenal and stomach biopsies also showed enteritis with ulceration and gastritis. The patient met the criteria for phenotypic UC given no granulomas, perianal disease, segmental colitis, rectal sparing, cobblestoning or stricturing of the terminal ileum (TI), and normal growth parameters. She was treated with mesalamine, lansoprazole, azathioprine, and prednisone but had multiple flare-ups in the next two years despite treatment with infliximab, adalimumab, vedolizumab, and ustekinumab. Repeat colonoscopies at age 12 and 14 years showed left-sided colitis without granulomas with normal transverse, right colon, and TI. The next year she had an abdominal abscess and perforation requiring a subtotal colectomy. Biopsy showed severe diffuse chronic active intermediate colitis, superficial and deep perforating fissuring ulcers, transmural lymphoid aggregates, scattered transmural multinucleated giant cells, mild lymphoplasmacytosis, and occasional pseudopolyps. The rectal segment showed severe diffuse chronic active intermediate proctitis with peri-proctitis.

Although the patient‘s IBD was consistent with UC at the time of initial diagnosis, the presence of transmural inflammation, intra-abdominal abscesses, perforation was more consistent with a diagnosis of CD.

This case demonstrates we should always be cognizant of diseases with overlapping features and open to reevaluating our prior diagnoses. Multiple modalities help to distinguish CD from UC. p-ANCA is identified in 75% cases of UC and up to 20% in CD. Patients with CD limited to the colon have a higher prevalence of p-ANCA. Therefore p-ANCA is not useful in differentiating between UC and Crohn’s colitis.

266 Improving quality measures of hepatitis B care

MA Craig1*

B Waters1,2

1University of Tennessee Health Science Center, Memphis, TN

2VA Medical Center, Memphis, TN

Purpose of Study

The Department of Veterans Affairs (VA) created a national database to optimize treatment and screening of Hepatitis B (HBV). A previous study at the Memphis VA Medical Center (VAMC) measured quality metrics of HBV patients on antiviral therapy. This study observed quality measures in HBV patients not receiving antiviral treatment.

Methods Used

The VA national database included all patients in the Memphis area with positive Hepatitis B surface Antigen (HBsAg) tests. The VA Computerized Patient Record System was utilized to measure: linkage to care; hepatocellular carcinoma (HCC) screening, Hepatitis A antibody (HAV) screening, and hepatitis D antibody (HDV) screening. HCC screening was defined as imaging every six months by ultrasound, computerized tomography or magnetic resonance imaging. Deficient patients were called or mailed letters. The rates of delinquency before and after intervention were recorded.

Summary of Results

44 patients received antiviral therapy. 74 patients with HBsAg were not on antiviral therapy. Of these 74, 10 were excluded due to false positive tests. False positive HBsAg tests were associated with recent influenza or HBV vaccinations. Of the remaining 64 patients, 44 were immune/vaccinated for HAV, 47 were screened for HDV, 36 had HCC screening, and 45 were linked to care. During the study, 6 more patients were excluded from the final results: 1 patient had a brief reactivation of HBV during Hepatitis C treatment which resolved; 3 were found to be Hepatitis B Core antibody negative; 1 was initiated on treatment; 1 refused follow-up. Of the 58 remaining patients, 48 were immune/vaccinated for HAV, 47 had been tested for HDV, 41 were up to date on HCC screening, and 49 were linked to care. 9 did not respond to telephone or letter.

Abstract 266 Table 1

Conclusions

Intervention improved the percentage of Hepatitis B patients linked to care and quality measures. This study shows the promise of utilizing a national database to guide quality improvement studies.

267 Splanchnic vein thrombosis in acute pancreatitis: is anticoagulation appropriate?

A Deb*

T Thongtan

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Case Report

Splanchnic vein thrombosis (SVT) is a known complication of acute pancreatitis (AP) reported in about 10–16% cases. Anticoagulation therapy is commonly used to treat thrombosis, although current literature suggests that their use does not affect the clinical course but increases the risk of bleeding.

Case summary

A 36-year-old Hispanic man with a history of chronic severe alcoholism and hypertriglyceridemia presented with abdominal pain and vomiting for 1 day. He was found to have AP and hypovolemic shock requiring vasopressor support. His hospitalization was complicated by ARDS, respiratory failure requiring tracheostomy, abdominal compartment syndrome, and AKI needing dialysis.

On day 5 of admission, CT abdomen revealed fulminant necrotizing pancreatitis along with acute thrombosis of the portal vein, splenic vein, and superior mesenteric vein (figure 1). He was initially started on 40 mg enoxaparin for DVT prophylaxis and for SVT which was replaced with heparin drip (5000 U BID) due to imminent AKI. He developed upper GI bleeding from the ampulla along with hemorrhage in the pancreas. Heparin was discontinued and he underwent splenic artery embolization. Two weeks after the intervention, he developed significant GI bleeding requiring several units of blood transfusion shortly after low-dose enoxaparin (30 mg) was restarted. Enoxaparin was withheld during his subsequent course of hospital stay. A repeat CT abdomen 4 weeks later showed resolution of SVT.

Abstract 267 Figure 1

CT scan abdomen showing portal vein thrombosis

Conclusion

High risks of bleeding and unclear clinical benefit preclude the use of anticoagulation for SVT in patients with AP.

268 The therapeutic effect of topical capsaicin in treating cannabinoid hyperemesis syndrome

K Delgado*

Philadelphia College of Osteopathic Medicine – Georgia Campus, Jacksonville, FL

Case Report

Cannabinoid Hyperemesis Syndrome (CHS) is a diagnosis occasionally seen with chronic marijuana users. It presents with nausea, vomiting, and abdominal pain that improves with cessation of marijuana and hot showers. Treatment involves the use of an antiemetic, a PPI, and a pain medication. This report presents a case of severe, refractory CHS with resolution of abdominal pain and nausea after treatment with topical capsaicin. Literature shows that refractory CHS is sometimes managed with antipsychotics such as haloperidol or olanzapine (Sontineni et al., 2009). Unfortunately, these antipsychotics are known to cause many unwarranted side-effects. This case report suggests that topical capsaicin may be an effective option for refractory CHS patients.

A 21-year-old man presented to the ED with abdominal pain, nausea, and vomiting. He was given Ciprofloxacin, Flagyl, and Phenergan and was discharged the same day. Three days later, the patient presents to the ED with the same complaints and was admitted. The patient’s physical exam was unremarkable. He was treated with Morphine, Oxycodone, Protonix, and Ondansetron. CT imaging of the abdomen and pelvis was unremarkable. The patient mentioned that ‘taking a hot shower’ provides relief. CHS was suspected and urine toxicology came back positive for cannabinoids. Topical capsaicin cream 0.075% was applied in his lower abdomen, with reapplication every 4 hours. The patient reported significant improvement in his symptoms. He was discharged home with a prescription and was encouraged to discontinue marijuana use.

Discussion

CHS is becoming more prevalent due the legalization of marijuana throughout the United States. The approach in treating this is with opioid analgesics and antiemetics, but unfortunately the percentage of symptomatic relief among patients isn’t impressive. This study showed that topical capsaicin provided significant relief, therefore highlighting a possible treatment solution. There is little data in literature pertaining to the efficacy of topical capsaicin for CHS treatment. Therefore, this case report hopes to bring awareness on this promising alternative for CHS treatment. Other advantages of topical capsaicin are that it’s inexpensive, has low risk for side-effects, and it is well tolerated.

269 Does high procalcitonin in acetaminophen-induced hepatotoxicity indicate mortality?

E Elgwairi1*

A Abdalla2

N Eshak1

G Bedanie1

M Elmassry1

M Abohelwa1

J Abdelmalek1

M Zitun1

K Nugent1

C Jumper1

1TTUHSC, Lubbock, TX

2University of Benghazi, Benghazi, Libya

Case Report

Procalcitonin (PCT) is a useful diagnostic biomarker of bacterial infection and also reported to be elevated in acute liver failure (ALF), especially if secondary to acetaminophen toxicity. We report a case of acetaminophen-induced hepatotoxicity and death found to have a high PCT level without evidence of infection.

A 49-year-old female presented to the ER after being found unresponsive. Examination revealed a GCS of 5, normotensive, tachycardic, tachypneic and afebrile women. Her initial workup revealed a severe anion gap metabolic acidosis, elevated liver enzymes, high PT and INR, acetaminophen level of 449 mcg/mL, and lactic acidosis. She was admitted to the ICU, intubated, placed on N-Acetylcysteine and supportive treatment. She later required vasopressors and CRRT for persistent acidosis. Laboratory results showed worsening of liver functions while the acetaminophen level declined. The PCT was greater than 100 ng/mL on day 2&3. The patient‘s condition continued to deteriorate, and she passed away on the third day of hospitalization.

Acetaminophen overdose accounts for about half of ALF cases in the US. Finding a laboratory prognostic indicator may help in decreasing morbidity and mortality. Acetaminophen-induced hepatotoxicity patients have much higher PCT levels than other causes of ALF. High levels of PCT correlate with the extent of liver damage. Acetaminophen toxicity induces an inflammatory response, macrophage activation, and cytokines release, which may explain the high PCT. A recent study showed that hepatic macrophages are the cell source of hepatic PCT. A few articles mentioned that PCT level positively correlates with MELD scores and mortality in cirrhotic patients.

Recently, another acetaminophen-induced hepatotoxicity case was reported, presented with a lower level of transaminases, acetaminophen, PCT (45 ng/ml), and the patient recovered. In contrast, PCT was above 100 ng/ml in our case and resulted in a death. This may suggest a promising use of PCT as a prognostic factor and indicator of mortality in ALF. Prospective cohort studies are needed to determine the predictive value of PCT in acetaminophen-induced ALF.

270 A preliminary report on the role of virtual reality as a treatment for patients with functional nausea, vomiting and abdominal pain

ML Esteban*

K Espino

R McCallum

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Purpose of Study

Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that provides users with novel environments promoting distraction, relaxation and meditation. Multiple studies have proved its effectiveness in reducing pain of non-gastrointestinal etiologies and anxiety. This preliminary study investigates the utility of VR in patients with functional nausea and vomiting and abdominal pain.

Methods Used

Patients referred to an academic Neurogastroenterology and Motility Center at the Texas Tech University Health Sciences Center – El Paso from August to October 2020 with nausea, vomiting and/or abdominal pain not adequately responding to standard treatment were considered. After full disclosure and review of the VR programs, patients underwent a 30 minute to 1 hour VR session once or twice weekly and were coached regarding which programs to choose. Ongoing standard medical treatment was continued. A questionnaire grading symptoms as improved, same or worse was administered to the patients after each session.

Summary of Results

Four female patients aged 29 to 56 with nausea and abdominal pain were enrolled in this study with the following diagnoses: two rumination syndrome, one gastroparesis and one functional dyspepsia. All patients had at least one VR session during the study period. Results: Abdominal pain: three patients (75%) reported milder or no abdominal pain after the sessions compared to their baseline grading while one (25%) reported moderate abdominal pain. Nausea: three patients (75%) reported improvement in their nausea after the sessions compared to baseline while one (25%) with rumination syndrome noted worsening. Adverse effects reported were transient blurred vision, nausea and dizziness. All patients when questioned after completing the sessions and would consider this approach again and also recommend the treatment to other patients.

Conclusions

These preliminary results indicate that VR may be an effective as well as a safe adjunct in the management of patients with refractory functional nausea, vomiting and abdominal pain. A larger study with more treatment periods and longer follow-up to assess outcomes is being conducted.

271 Breaking the habit: resolution of cannibinoid hyperemesis syndrome with haloperidol

DS Gidla1*

S Pagliolongase2

M Oye1

MB Omar

P Reddy

1University of Florida College of Medicine – Jacksonville, Jacksonville, FL

2Alabama College of Osteopathic Medicine, Dothan, AL

Case Report

An 18 year old female with a history of anxiety presented with intractable nausea and vomitting for 3 weeks duration. She had a history of multiple hospitalisations during this period without significant improvement. This was associated with worsening of anxiety and frequency of panic attacks. She had no prior medical history. Physcial exam was unremarkable. An extensive work up was unrevealing, including infectious, endocrine, pregnancy, heavy metal, porphyrin screening and CT abdomen. Upon further questioning she admitted to daily inhalational cannabis use for the past year and endorsed increased frequency of hot showers to alleviate symptoms. During this admission, symptoms remained refractory to aggressive therapy with multiple antiemetics. Salvage therapies were attempted with benzodiazepines and sumitriptan without relief. She was then administered a single intravenous dose of haloperidol 2 mg which succeeded in resolution of symptoms and significant decrease in patient anxiety.

As legislature changes the increasing incidence of Cannabinoid Hyperemesis Syndrome (CHS) may be seen. It is found is young adults who have a history of daily long term use. Though the mechanism of CHS is yet unknown, the clinical course is well described in the literature. It typically involves a Prodromal Phase, a Hyperemetic phase and a Recovery phase. Patients usually seek medical advice during the dramatic nausea and vomitting that occurs during the hyperemetic phase. Typically patients are found to have multiple emergency room admissions before diagnosis is made and suffer symptoms until diagnosis is made as first line anti-emetics which are commonly not effective in resolving symptoms. Salvage therapy with typical antipsychotics such as haldol has been demonstrated to show greater efficacy in management of CHS. In cases such as ours, its early use in patients with a suspicion of CHS whose symptoms are refractory to first-line treatment may allow earlier resolutions of patient symptoms, speed the formulation of a diagnosis and reduce the level of unnecessary testing in patients with CHS.

272 Gallbladder adenocarcinoma. The impact of tumor location and minimally invasive surgery on survival

M Hamdan1*

F Maegawa2

S Joseph1

M Ahmad1

A Barrientes1

S Chiba1

A Philipovskiy1

S Elhanafi1

A Tyroch1

I Konstantinidis1

1Texas Tech University Health Sciences Center, El Paso, TX

2University of Arizona, Tucson, AZ

Purpose of Study

There is evidence that T2 gallbladder adenocarcinoma (GBC) located on the peritoneal side has improved survival vs. on the liver side.

Methods Used

The National Cancer Database was queried for the location of GBC within the gallbladder, mode of surgery, and extent of hepatectomy from 2010 to 2016. Kaplan-Meier and log-rank test were used for survival comparisons.

Summary of Results

A total of 3308 patients with GBC were identified, of whom 1284 (38.8%) underwent a hepatectomy. Tumors occupied the hepatic and peritoneal sides in 19%, had the highest R1 margin, readmission, and 90-day mortality rates. In patients who underwent hepatectomy, peritoneal side tumors had improved survival compared to the liver or both sides (OS: 58mo vs.29mo vs.23mo; p<0.001). By T stage, tumors on the peritoneal vs. liver side had similar outcomes (T1: 72mo vs. 67mo; p=0.5, T2: 31.9mo vs. 32mo; p=0.9, T3: 11mo vs.14.6mo; p=0.1, T4: 10 mo vs. 9.4mo; p=0.3, respectively). Minimally invasive surgery (MIS) was increasingly utilized and is associated with shorter hospitalizations without a negative impact on survival.

Abstract 272 Figure 1

Survival outcomes for 3308 patients who had GBC resected according to tumor location. Patients with peritoneal side tumors (n=737) had a significantly improved survival over patients with liver side tumors (n=1946) or both sides (n=625) (MedianOS:26.5mo vs. 21.3mo vs. 14mo; p<0.001)

Conclusions

GBC on the peritoneal and liver sides is associated with the worst outcomes. Peritoneal side tumors have similar survival to tumors located on the liver side for each T1-4 stage. MIS approaches do not have a negative impact on survival.

273 Pancreatic pseudocyst resulting from a jellyfish sting

B Jafar*

D Gremse

University of South Alabama, Mobile, AL

Case Report

Acute pancreatitis is a sudden inflammatory process of the pancreas leading to acinar cell death. One of the known complications is a pancreatic pseudocyst. We report the first case of pancreatic pseudocyst secondary to a jellyfish sting.

A previously healthy 10-year-old Caucasian developed crampy right lower quadrant and epigastric abdominal pain, along with multiple episodes of non-projectile emesis of gastric content, anorexia, and fatigue within 24 hours of being stung by a jellyfish. There was no history of trauma or medication use. Laboratory testing showed elevated lipase, leukocytosis with left shift, thrombocytosis, and elevated CRP. CT abdomen showed pancreatic phlegmon. CXR showed right lower lobe pneumonia. Treatment included IVF, Piperacillin/Tazobactam, and Vancomycin for the treatment of pneumonia. After 7 days of therapy, ongoing signs of inflammation led to the addition of Levofloxacin followed by Meropenem 2 days later. 12 days after onset, she developed a fever of 38.3C. Repeat testing showed worsening leukocytosis and CRP. A repeat CT abdomen and chest demonstrated a pseudocyst measuring 13.5 cm and pancreatic necrosis. Laboratory testing showed a serum lipase of 1300, metabolic acidosis, hypoalbuminemia, and mild transaminitis. The patient also had normocytic anemia, leukocytosis with a neutrophilic predominance, and elevated CRP. Lipase was repeated the next day and was found to be 1212. Amylase was 127. The urine and blood culture were negative.

CT abdomen showed acute pancreatitis and a pseudocyst measuring 13.5 cm. Laboratory results showed elevated lipase and inflammatory markers. The patient was started on IV antibiotics, kept NPO, and PPI. MRCP showed large simple appearing cystic structure arising from the distal body of the pancreas measuring up to 11.6 × 10.4 × 12.4 cm. which appeared to be arising from the pancreatic duct. The patient was extensively investigated, and all other causes of AP were ruled out. US Abdomen showed a large, lobulated low echogenic mass in the region of the pancreas consistent with a pancreatic pseudocyst, measuring at 12.7 × 7.5 × 7.7 cm. with noted internal echoes.

This demonstrates that acute pancreatitis may occur in association with a jellyfish sting. We conclude that acute pancreatitis should be considered in patients with abdominal pain and vomiting following a jellyfish sting.

274 Larger preterm infants do not show growth benefits from nutrient enriched post-discharge formula at 6 month follow up

J Julia1*

J Davis1

CL Blanco1

S Abrams2

1UT Health, San Antonio, San Antonio, TX

2UT Health, Austin, Austin, TX

Purpose of Study

Current recommendations to discharge infants on nutrient enriched feeding regimens are based on studies with limited benefit in the smallest infants. This study investigates if discharging preterm infants with birth weight (BW) >1500 g on nutrient enriched post-discharge formula shows improved growth parameters at 6 months (mo).

Methods Used

Charts of all infants admitted to the University Hospital (UH) NICU in 2018 with BW > 1500 g and GA < 37 0/7 were reviewed. Those with 6mo follow up at UH were included. Patients were analyzed in two groups (1) no fortification at discharge (DC) and (2) any fortification at DC. Primary outcomes were change in z-score for weight, length, and FOC from discharge to 6-month follow up.

Summary of Results

278 infants were admitted to the NICU with GA < 37 0/7 weeks and BW > 1500 g. 28 (10.1%) met exclusion criteria, 104 (37.4%) had follow up at 6mo, and 146 (52.5%) had no 6mo follow up. Baseline characteristics of included patients showed increased rates of BPD and lower mean GA and BW than those without follow up. Of those included, 16 (15.4%) received no fortification at DC and remained unfortified at 6mo follow up, 88 (84.6%) were discharged on fortification, but only 55 (52.9%) remained fortified at 6mo. Comparing those receiving any fortification to those unfortified at DC, there were no differences between groups in the primary outcomes of change in z-score for weight (p = 0.457, overall mean change Z-score +0.63), length (p = 0.236, mean +0.14), or FOC (p = 0.272, mean +0.672) at 6mo follow up. There was also no difference in change in z-score for weight, length, or FOC between infants that remained completely unfortified, those discharged on fortification but unfortified at 6 mo, and infants which remained fortified (p > 0.05 for all).

Conclusions

In preterm infants with BW > 1500 g admitted to the UH NICU in 2018 and followed until at least 6mo, feeding type at discharge does not affect growth outcomes at 6mo. Preterm infants discharged on unfortified feeds and those discharged on fortification but transitioned to unfortified feeds by 6mo showed similar growth to those who remained on fortified feeds.

275 Is gastroparesis always irreversible in a diabetic?

M Kalas*

GM Galura

I Sarosiek

R McCallum

Texas Tech University Health Sciences Center El Paso, El Paso, TX

Introduction

Gastroparesis(GP) is a syndrome characterized by postprandial nausea, vomiting, abdominal pain, and fullness with a prevalence of approximately 10 million in the US and >70% of patients are females. The severity and persistence of symptoms often lead to poor quality of life, frequent hospitalizations, and increased economic burden. GP etiologies include diabetes mellitus (DM), post-surgical, drugs, systemic diseases or idiopathic.

Case

57 year old female with a 16 year history of type 2 DM presents to the clinic with a history of nausea, vomiting, early satiety, abdominal fullness and bloating of some years duration. Laboratory tests were remarkable for an HbA1C of 8.2%. Prior upper and lower endoscopy showed no obstruction and no previous gastric emptying study (GES) had been done. Upon further history taking, it was found that she started dulaglutide 1 year ago. A 4-hour GES was scheduled and showed 35% retention of isotope at 4 hours, indicating delayed gastric emptying (< 10% is normal). Dulaglutide was held for 4 weeks and symptoms resolved. A repeat GES showed 3% of isotope retained in the stomach at 4 hours, which is normal.

Discussion

The diagnosis of GP requires evidence of delayed gastric emptying (GE) in the absence of mechanical obstruction. Prolonged DM (> 5 years) can result in GP due to irreversible neuronal damage from poor glycemic control and is irreversible. Drugs such as PPIs, levodopa, calcium channel blockers, marijuana, opiates, and GLP-1 agonists are also associated with delayed GE. GLP-1 agonists such as Dulaglutide act by binding to incretin receptors resulting in insulin release and glucagon suppression. Moreover, GLP-1 agonists inhibit antral and duodenal motility and increase pyloric pressure which slows GE. GLP-1 agonists are growing in popularity due to their convenient subcutaneous weekly dosing and their favorable weight loss side effect.

This report highlights the under recognized role of gastroparesis induced by GLP-1 agonists and how a detailed history is crucial in differentiating drug induced GP which is reversible in contrast to diabetic GP.

276 Heparin, the savior for the acute management of hypertriglyceridemia

F Kandah*

R Shukla

J Ruiz

University of Florida Health Science Center Jacksonville, Jacksonville, FL

Case Report

A 52 year old male with past medical history of hypertension and Barrett’s esophagus presented for evaluation of hypertriglyceridemia at the request of his primary care physician. His symptoms included recent difficulty tolerating oral intake with associated watery diarrhea. Per labs from his primary care office two days prior, he had triglyceride levels of greater than 1800 and lipase of 121. Upon admission, his blood work was significant for a lipase level of 61 and triglyceride level further elevated to 2900. On bedside exam, the patient was resting comfortably and endorsed mild abdominal pain with deep palpation in the epigastric region. He was hemodynamically stable and admitted for further management and workup of possible pancreatitis. He was started on aggressive fluid resuscitation and pain control. As the patient remained a very low bleeding risk, he was also started on heparin drip. Less than twelve hours later, follow up triglyceride levels had decreased to 1200, and the patient denied any further symptoms. As he remained asymptomatic with downtrending triglyceride levels, the heparin drip was discontinued, and the patient was discharged on oral medications of atorvastatin and fenofibrate.

Discussion

This case illustrates the potential of rapid reduction of severe levels of triglyceridemia via monotherapy in a controlled setting. Oral medications including fibrates or statins are known to produce similar effects over longer settings of time. There are currently no established guidelines for the acute management of severe hypertriglyceridemia. Those that present with acute pancreatitis are treated with the standard management of nothing by mouth, intravenous fluids, and pain control. Hypertriglyceridemia-induced pancreatitis has several other effective treatment modalities that are seen in literature. Insulin and heparin are frequently used in these cases, mainly due to their effect on the LPL enzyme which assists in removing triglycerides from plasma.

Unfortunately, many cases of primary hypertriglyceridemia may present either spontaneously or in patients with poor medication compliance. Therefore, further investigation into insulin or heparin therapy to reduce severely elevated TG levels in the acute setting would prove beneficial.

277 Gluten-free diet ineffective in remission response of eosinophilic esophagitis in child also diagnosed with celiac disease

K Lemes1*

K McGoogan2

1University of Florida College of Medicine, Jacksonville, FL

2Nemours Children’s Specialty Care, Jacksonville, FL

Purpose of Study

Celiac Disease (CD) and Eosinophilic Esophagitis (EoE) are two distinct chronic immune mediated gastrointestinal disorders with unique differences in clinical and histopathological features. Numerous studies have indicated an association between these two diseases with increased prevalence of CD in patients diagnosed with EoE. The co-treatment of these diseases, however, has not been well described. The purpose of this report is to examine a case of a child diagnosed with both CD and EoE, placed on a gluten-free diet and proton-pump inhibitor (PPI) without remission of EoE on repeat endoscopy.

Methods Used

The case report included a patient diagnosed with both CD and EoE based on endoscopy and histopathological findings treated with a gluten-free diet and PPI. The patient’s presentation, laboratory results, and histopathology reports of esophageal and duodenal biopsies were reviewed.

Summary of Results

In this case report, we describe an 11-year old male who presented with esophageal food impaction. During endoscopic procedure, the patient was found to have EoE on visualization of the distal portion of the esophagus confirmed with histopathology report. The patient was also noted to have evidence of villous blunting in the duodenum consistent with CD which was confirmed by elevated celiac antibodies. While a strict gluten-free diet is the only effective therapy for CD, there are several therapeutic options, such as PPI, swallowed topical steroids, and dietary elimination therapy for EoE, one of which includes gluten containing foods. The patient’s parents opted to try a PPI and gluten-free diet for treatment of EoE and CD. This was continued for about 3 months at which point upper endoscopy was repeated. There was improvement in CD based on both lab work and histopathology of duodenal biopsies, but EoE did not show remission. This suggests that a gluten-free diet alone may not be adequate for the treatment of both EoE and CD.

Conclusions

This case report suggests that a gluten-free diet alone and/or PPI may not be enough to induce remission of EoE in patient also diagnosed with CD and that further food elimination diet or topical corticosteroids may be warranted.

278 A case of eosinophilic colitis and CMV positive menetrier disease

S Leon Paredes*

CI Chinchilla Putzeys

MR Roca Garcia

University of South Alabama, Mobile, AL

Case Report

Protein-losing enteropathy (PLE) is characterized by excessive loss of protein into the gastrointestinal tract due to impairment of the mucosa. This case report describes the clinical course of a patient diagnosed with eosinophilic colitis coexisting with Ménétrier disease.

A 5 year-old male presented with constipation, postprandial emesis and abdominal distention for 2 weeks. Physical exam findings were abdominal distention and tenderness. Blood workup revealed absolute eosinophilia. Administration of polyethylene glycol and milk of molasses enema resulted in worsening abdominal distention. Later, he developed scrotal and penile edema. Serum albumin decreased from 2.2 g/dL on admission to 1.1. Urinalysis, stool PCR multiplex, fecal elastase and anti-TTG, stool ova and parasites, HSV antigen and antibodies were negative. Fecal alpha-1-antitrypsin was elevated. Endoscopy showed candida esophagitis and erosive gastritis with rugal hypertrophy, suspicious for Menetrier disease. Cytologic evaluation reported eosinophilic infiltration of the esophagus, stomach, and ascending colon to rectum, sparing cecum and duodenum. No fungal hyphae or cytopathic changes of CMV were demonstrated. Further blood work revealed negative HIV and CMV IgM, elevated CMV IgG and low level CMV viremia on serum PCR. Specific IgE blood test positive to egg, wheat, and milk.

Intravenous albumin infusion and treatment for erosive gastritis, constipation and six-food elimination diet resulted in improvement of symptoms.

Ménétrier disease is characterized by irregular hypertrophic gastric folds and epithelial hyperplasia causing leakage of protein into the lumen.

The disease is idiopathic, associated to Helicobacter pylori in adults and CMV, HSV and rarely to H. pylori in children.

The differential diagnoses include inflammatory bowel disease, eosinophilic gastrointestinal disorders, celiac disease and lymphoma. The diagnosis requires an elevated stool alpha-1-antitrypsin and a full gastric mucosal biopsy.

PLE is rare, more so, the finding of two entities in a patient. This case report shows the importance of a thorough work up as different etiologies may explain the patient‘s presentation.

279 Total parenteral nutrition, cholestasis, and gallstones in infancy: a rare case

GB Maniam*

D Ukwade

S Tijani

GB Tardieu

R Mattamal

Texas Tech University Health Science Center, Amarillo, TX

Case Report

Cholelithiasis is rare in infancy, although the rates of diagnosis have increased as a result of the widespread use of ultrasonography in neonates. Most cases of neonatal cholelithiasis are due to hemolysis or an abnormality in the biliary tree or ileal tract; TPN administration is a lesser-known risk factor for the development of this condition. This case presents an infant who developed gallstones due to cholestasis secondary to TPN administration.

A 3-year-old girl presented to the emergency department with severe abdominal pain, which she rated as 8 of 10 in severity. The onset of the pain had occurred that morning during a long car ride. She described the pain as crampy and reported that it had begun in the right upper quadrant but had since become diffuse throughout the abdomen. Related symptoms included reduced activity and refusing to eat or drink; the mother also reported that the girl had foul-smelling urine. The patient denied fever, headache, nausea, vomiting, diarrhea, rash, or difficulty breathing. Her medical history was notable for gastroschisis (which had been surgically repaired on day 9 of life) that had been complicated by a 10-cm ventral hernia and cholestatic jaundice secondary to prolonged TPN administration in NICU. The cholestatic jaundice had resolved, but the hernia remained unresolved. The patient was admitted to the hospital and was ordered to have nothing by mouth with nasogastric tube placement. Laboratory studies were notable for an elevated white blood cell count. An ultrasonogram of the abdomen revealed cholelithiasis without bowel obstruction. One day following hospital admission, a surgical consultant recommended laparoscopic cholecystectomy and hernia repair. The procedure was performed the following day, during which cholesterol gallstones were found, but without any other complications. The patient was evaluated the next day, and discharge was recommended with a follow-up visit in 2 weeks.

Recognition and treatment of cholelithiasis secondary to TPN is rare in such young patients, clinicians should keep these causes in the list of differential diagnoses when presented with an infant with such symptoms and a history of prolonged TPN administration.

280 Gastrointestinal neuroendocrine tumors: a rare, indolent neoplasm on the rise

M Masood*

J Ertle

Augusta University, Augusta, GA

Introduction

Gastrointestinal neuroendocrine tumors (NETs) are a rare entity, but their incidence has vastly increased in recent years. The diagnosis is often delayed due to a variable presentation and an indolent course. Novel therapies have emerged which aid in the management of NETs.

Case presentation

A 77-year-old Caucasian male with a history of Alzheimer’s dementia and abdominal hernia repair who presented for abdominal pain of one-day duration. He denied nausea, vomiting, changes in stool, or dysuria. Vital signs were unremarkable. Examination was significant for lower abdominal tenderness. Laboratory studies were notable for a leukocyte count of 15,600/mm3, hemoglobin of 10.6 g/dl and a platelet count of 651,000/mm3. Contrast-enhanced, abdominopelvic computed tomography (CT) scan revealed a partial small bowel obstruction due to a 1.6 cm x 1.4 cm enhancing, intraluminal lesion near the ileum with mesenteric lymphadenopathy. The patient’s symptoms improved with conservative measures and he was discharged home. Resection of the lesion revealed two well-differentiated neuroendocrine tumors in the jejunum. Immunohistochemical staining of the lesions was positive for chromogranin A and synaptophysin with a Ki-67 index of 15%.

Discussion

While the incidence rate of gastrointestinal NETs has been reported to be 1.05 per 100,000, the incidence is steadily increasing, likely due to more frequent imaging and endoscopy. NETs are often slow-growing and have a non-specific presentation which can make the diagnosis challenging. Patients may be asymptomatic, have obstructive symptoms, such as in this case, or report symptoms related to tumor production of bioactive substances, as in carcinoid syndrome. NETs may secrete chromogranin A and synaptophysin which can be used for confirmation or surveillance of disease. Patients with localized disease are often treated with surgical resection. Somatostatin analogs and cytoreductive surgery are usually reserved for metastatic disease. Peptide receptor radionuclide therapy (PRRT) has emerged as the therapy of choice for progressive disease on somatostatin treatment. Given the increased incidence and often-delayed diagnosis of NETs, it is paramount that clinicians recognize and understand this disease. Early efforts should be made to diagnose and manage NETs using a multidisciplinary approach.

281 A root cause for dysphagia: vegetable food impaction mimicking esophageal malignancy

P Nethala*

A Edwards

University of Alabama at Birmingham, Birmingham, AL

Case Report

Food bolus impactions are medical emergencies that are usually meat associated, with vegetables making up less than 5% of documented cases. Structural abnormalities including reflux esophagitis may predispose to impactions, and edentulous patients or those with poorly fitting dentures are at increased risk for impaction due to ineffective chewing and decreased tactile sensation while swallowing. We present an 82 year old woman with dementia and edentulism presented with acute onset dysphagia to solids for 3 days. On examination she had normal vital signs. Her oropharyngeal exam showed loose fitting dentures, and her thyroid exam was normal. A barium esophagram showed a large, at least 3 cm well-defined round lesion within the distal esophagus (figure 1A), concerning for esophageal malignancy. Upper endoscopy showed a 3.5 cm diameter orange-brown disc-shaped foreign body in the distal esophagus (figure 1B) that was removed with a net retrieval basket. On inspection the foreign body was consistent with a slice of raw carrot (figure 1C). Two months after her upper endoscopy her weight was stable with no further dysphagia. A repeat esophagram showed a 2 cm hiatal hernia and no evidence of a distal stricture. We present this case to highlight a minority etiology for food bolus impaction and to highlight underlying structural complications that can predispose to impactions.

Abstract 281 Figure 1A

Barium esophagram with arrow indicating a well-circumscribed lesion in distal esophagus concerning for malignancy

Abstract 281 Figure 1B

Disc shaped foreign body seen on EGD in distal esophagus

Abstract 281 Figure 1C

3.5 cm removed distal esophageal lesion, consistent with raw carrot slice

282 It’s complicated: monitoring after paracentesis

D Roman Colon*

M Ortiz

VA Caribbean Healthcare System, San Juan, Puerto Rico

Case Report

Abdominal paracentesis is a diagnostic and therapeutic procedure deemed safe. Complications are seen in 1% of cases, delayed hemoperitoneum from preceding large-volume paracentesis is extremely rare. Its presentation is subtle and confers motality rates >70%. High index of clinical suspicion for prompt diagnosis is possible with awareness. This is a case where delayed hemoperitoneum presenting 72 hours after large-volume paracentesis was succesfully managed with conservative measures.

A 60-year-old male with class B Child-Pugh cirrhosis secondary to alcohol abuse presented with 3-weeks of bilateral lower extremity edema extending to scrotum and increased abdominal girth. Physical examination revealed a globose, tense distended abdomen without tenderness to palpation, + fluid wave, and bilateral pitting edema. Ultrasound-guided paracentesis in the left lower quadrant yielded 5.6 L of clear, ascitic fluid compatible with portal hypertension. No hematomas were observed, rapid symptomatic relief was achieved, and albumin was replaced. Three days later the patient referred mild, diffuse abdominal discomfort with a hemoglobin drop to 6.5 g/dL from 10.3 g/dL without evidence of hematomas or bleeding. He was hemodynamically stable, 1 unit PRBC and 2 FFP transfused with resulting hemoglobin >7 g/dL. Abdominal imaging revealed large volume ascites and high-density fluid suggestive of hemoperitoneum. Serial hemoglobin levels remained stable and no further transfusions warranted. Given tense refractory ascites with associated shortness of breath, patient required two paracentesis which demonstrated blood-tinged, ascitic fluid and provided symptomatic relief. Patient was discharged home with spironolactone and furosemide in 5:2 ratio.

Delayed hemoperitoneum is believed to occur secondary to a rapid drop in intraperitoneal pressure following large fluid removal that cause mesenteric varices to rupture. Common symptoms include vague abdominal discomfort, distension, and shock. It may require aggressive transfusions, exploratory surgery, or transjugular intrahepatic portosystemic shunts. Prompt recognition of this complication can prevent invasive intervention and is critical due to its high mortality rate. Close surveillance in these patients, lower-volume paracentesis, and slower drainage of ascites is recommended.

283 Amber eyes: a tale of a choledochal cyst

J Sansone*

N Zeky

C LeBlanc

P Arias

Louisiana State University Health Sciences Center, New Orleans, LA

Case Report

Despite abdominal pain being a common pediatric complaint, choledochal cysts must be considered when a history includes jaundice and abdominal mass. Choledochal cysts are defined by biliary tree dilatation and obstruction. This disease presents most often in infancy and childhood with an incidence of around 1 in 100,000.

A previously healthy 10 year old girl presented to her doctor with 2 weeks of abdominal distension and scleral icterus. Her initial work up revealed a direct hyperbilirubinemia, Alkaline Phosphatase of 753 U/L, Aspartate Aminotransferase of 291 U/L, Alanine Aminotransferase of 222 U/L, and Gamma-Glutamyl Transferase of 633 U/L. Evidence of obstructive jaundice led to an abdominal ultrasound. This revealed dilatation of the common bile duct, gallbladder, and intrahepatic bile ducts. Magnetic Resonance Cholangiopancreatography confirmed a Type IVa choledochal cyst. She underwent Choledochal Cyst Excision and Hepaticojejunostomy.

Although a rare etiology in school age children, choledochal cysts need to be considered for this presentation. Choledochal Cysts should be recognized early with rapid intervention to prevent lifelong complications including liver failure and cholangiocarcinoma. An abdominal ultrasound is the preferred initial screening test, followed by an MRCP with Eovist to further characterize the lesion.

284 A mysterious case of chronic diarrhea not responsive to treatment

T Thongtan*

GD Bedanie

A Deb

K Nugent

Texas Tech University Health Sciences Center, Lubbock, TX

Introduction

Chronic diarrhea is a leading cause of health care utilization worldwide. While a specific diagnosis can be achieved in > 90% of patients, many do not have a conclusive diagnosis and more case reports are needed.

Case Report

A 47-year-old man with type 2 diabetes, hypertension, substance abuse, chronic kidney disease, old stroke, and untreated chronic hepatitis C infection presented with chronic diarrhea for 1 year. He endorsed lower abdominal pain and bloating. During a hospital stay, he had been having constant diarrhea up to 12 times/day and complete loss of bowel control with observed loose stool every day. Despite extensive workup undertaken, there was no known cause of his chronic diarrhea. The empiric treatment regimens used in sequence included low-carb/lactose-free diet, rifaximin, Welchol, cholestyramine, pancrelipase, albendazole, and loperamide failed to improve his secretory diarrhea. His hypovolemia from ongoing diarrhea led to end-stage renal disease with severe metabolic acidosis and hyperkalemia needing hemodialysis. He developed Enterobacter cloacae complex aspiration pneumonia and acute hypoxemic respiratory failure. The patient died on hospital day 64.

Abstract 284 Table 1

Summary of diagnostic tests for chronic diarrhea

Discussion

Chronic diarrhea is a diagnostic challenge with hundreds of possible causes. Physicians should determine the category of diarrhea based on stool appearance into fatty, watery, or inflammatory. Empiric therapy is reasonable if a specific diagnosis was suspected. Life-threatening conditions should be excluded. We reported a case of a patient with chronic severe secretory diarrhea that remains unknown and unsolved for the etiology.

285 The mystery of analgesic refractory chest pain

H Yousuf*

RI Hazam

D Dave

KN Abdelmalek

I Ivyanskiy

N Elzubeir

N Rus

Texas Tech University of Health and Sciences, Amarillo, TX

Case Report

Chest pain has a wide differential diagnosis. It is important for clinicians to recognize the atypical presentations of esophageal carcinomas as chest pain. We report a case of a patient with esophageal carcinoma resistant to analgesics who presented with chest pain only.

A 61-year-old male presented with sudden onset, severe, non-radiating right-sided sharp chest pain for 8 days that increased on deep breathing. The exam was unremarkable but for a heart rate of 119 bpm. Lab findings, cardiac enzymes, and chest radiographs were unremarkable. ECG revealed sinus tachycardia. CT angiogram and the duplex US of the abdomen were unremarkable. Abdominal CT showed thickened gastroesophageal junction, concerning an underlying neoplasm with lymphadenopathy and invasion of the pancreatic body. EGD findings showed a large, ulcerated, non-circumferential mass just below the GE junction at 45 cm with no bleeding. Another large, partially obstructing, the noncircumferential ulcerating mass was found in the distal esophagus, extending from 39 cm to 45 cm cm from the incisors along with esophageal mucosal changes suspicious for long-segment, Barrett’s esophagus and moderately differentiated adenocarcinoma of the GE junction, clinically categorized as stage IV, T4 N3 MX. The patient opted for palliative chemotherapy.

Metastatic cancer can masquerade as retrosternal chest pain. About 74% of these patients present with dysphagia, 17% report odynophagia, 57% report weight loss, and 21% report long-standing GERD. But when the patient presents with retrosternal or right upper abdominal pain it usually reflects the presence of unresectable, extensive disease.

Physicians should recognize that persistent pain that is disproportionate to the exam findings is an important clue for possible unresectable extensive malignant disease

286 Gallbladder agenesis in a middle-aged female with nausea and right upper quadrant pain

H Yousuf*

MA Tanbir

RI Hazam

I Obokhare

T Naguib

Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX

Background

With an incidence of 1/6500 live births, gallbladder agenesis (GA) is a rare congenital condition. While majority of patients are asymptomatic, those who do develop symptoms present similarly to cholecystitis and have similar findings on ultrasound evaluation.

Case presentation

We present the case of a 35-year-old female with recurrent hospitalizations for 1 year due to postprandial nausea, vomiting and right upper quadrant pain. Vitals were stable except for tachypnea. Physical exam revealed epigastric and right upper quadrant abdominal tenderness on deep palpation. She had leukocytosis and right upper quadrant ultrasound showed contracted, thickened gallbladder with no ductal dilatation.

Patient underwent diagnostic laparoscopy with lysis of stomach/duodenal adhesions and ICG dye cholangiography. No gallbladder was noted during surgery. Post-operative CT scan (figure 1) confirmed absence of gallbladder. Subsequent Nuclear Medicine Hepatobiliary Duct System Imaging also confirmed it by nonvisualization of the gallbladder after 4 hours with a patent common bile duct.

Conclusion

Due to the similarity with biliary colic and rarity of the disease, GA is often diagnosed intraoperatively, and this was the case with our patient.

Abstract 286 Figure 1

CT Abdomen

287 A little dili for your spider bite

K Zamora*

S Homra

B Lanoux

H Oddo Moise

V Thibodeaux

M Rees

LS Engel

S Walvekar

LSU Health Sciences Center, New Orleans, LA

Case Report

A 45-year-old woman with a history of gastric bypass surgery, recently treated hepatitis C, alcohol and cocaine abuse presented to the Emergency Department with two weeks of epigastric abdominal pain associated with fevers, chills, diffuse myalgias, fatigue, early satiety, nausea, and dark-colored urine. Further review of systems was notable for a recent spider bite which was treated with 3 days of amoxicillin, followed by 6 days of oral Trimethoprim-sulfamethoxazole (TMP-SMX) 40–200 mg/5 mL suspension BID about 3 weeks. She was concurrently on a course of doxycycline for presumed endometritis. On physical exam, she had a positive Murphy’s sign, jaundice and scleral icterus. Laboratory studies showed AST 137 U/L, ALT 136 U/L, ALP 688 U/L, total bilirubin 4.6 mg/dl, and GGT 306 U/L. RUQ ultrasound was significant for gallbladder wall thickening and increased vascularity in the wall of the gallbladder. CT abdomen showed no evidence of gallbladder obstruction or cholecystitis. MRCP confirmed no biliary obstruction. Work up for infectious, obstructive, autoimmune, and genetic etiologies was unremarkable. All potentially hepatotoxic medications were stopped but worsening of liver function continued, stabilized, and then began to decline over the course of her hospital stay. Liver biopsy revealed granulomatous hepatitis with irregular peri-granulomatous and background large-droplet steatosis that, in the setting of negative laboratory work-up, led to the diagnosis of TMP-SMX-induced granulomatous hepatitis with predominant cholestasis. She was started on ursodiol and discharged with outpatient follow-up.

Discussion

TMP-SMX-induced liver injury can range from mild liver enzyme elevations to acute liver injury. Most cases resolve quickly, within 2–8 weeks, but can last for months in cases of severe cholestasis. Some documented cases have resulted in the need for a liver transplant. In most cases sulfonamide is the causative agent, but trimethoprim also has associated cases of hepatotoxicity, so it is best to avoid switching to trimethoprim alone and identify the patient as allergic to TMP-SMX. Liver injury with the use of TMP-SMX is rare relative to the widespread use of this drug, and this case illustrates that even short courses may put a patient at risk.

288 The ripening process: finding the perfect balance between tuberculosis and ulcerative colitis

N Zeky*

E McDonough

R Zwiener

LSUHSC-Children’s Hospital of New Orleans, New Orleans, LA

Case Report

A 15-year-old previously healthy female presented to the emergency room for hematochezia, ultimately diagnosed with ulcerative colitis (UC) on colonoscopy. She was started on infliximab. Prior to initiating this therapy, she had a positive T spot however was having no respiratory symptoms, indicating latent tuberculosis (TB). Isoniazid and rifampin were started. Over the next five months, she was poorly compliant with her latent TB therapy. She was admitted to the hospital at this time, received methylprednisolone and had a documented calprotectin of >1,000 mcg/g, consistent with an UC flare. Shortly after this admission, she was readmitted for fever, cough, night sweats, pleuritic chest pain and diagnosed with active pulmonary TB. This admission included the discontinuation of infliximab and active pulmonary TB therapy, including rifampin, isoniazid, pyrazinamide, and ethambutol were started. At the conclusion of this admission, her calprotectin had trended down to a normal value of <16 mcg/g, despite no therapy for UC for two months.

Follow up from the hospital, she was asymptomatic. There were plans to repeat her colonoscopy. This got delayed and when she finally returned to for her follow up, ten months after stopping her infliximab she was now reporting some hematochezia, her calprotectin was now documented to be >3000 mcg/g, and her colonoscopy showed severe active colitis. Her TB therapy was in its final month to complete the course.

It is well documented that the use of tumor necrosis factor (TNF alpha) inhibitors increases the risk of reactivation of latent TB and it is why TB screening is done prior to induction therapy. When patients have latent TB, it is acceptable to start TNF alpha therapy with close monitoring for reactivation. It is unclear if this patient had reactivation from use of steroid taper during the flare up or was her underlying noncompliance playing more of a role. There is also a possibility that some of her TB therapy could have a played a role at controlling the inflammation of her UC.

Health care research, quality improvement, patient safety and population health & precision medicine

Joint plenary poster session

4:30 PM

Thursday, February 25, 2021
289 Improved screening for sexually transmitted infections among hospitalized youth: a quality improvement project

F Abene*

R Chong

N Gordon

A Nasrazadani

S Patel

RM Beyda

The University of Texas Health Science Center at Houston, Houston, TX

Purpose of Study

Only 10% of adolescents admitted to the hospital receive the appropriate sexually transmitted infection (STI) screening recommended by the AAP. Lack of appropriate screening for STI in adolescents creates significant morbidity and elevates healthcare costs. Cases of gonorrhea, chlamydia (GC/CT) and syphilis have increased significantly since 2013. Youth often forego routine health visits and admission to the hospital may be their only interaction with healthcare providers. In our institution, screening is inconsistent and at the discretion of the physician. The aim of our quality improvement project was to increase screening among youth ages 16–18 years old admitted to the primary pediatric service in our children’s hospital.

Methods Used

Our study population included youth ages 16–18 years old admitted to Children’s Memorial Hermann Hospital from August 2019 to January 2020. A retrospective chart review from August to October 2019 determined baseline screening rates. The intervention took place in November 2019 and included 3 phases. First, residents were educated during their academic half-day and intern orientation regarding screening. Second, cue cards were placed on the mobile physician computer workstations, flyers were hung in the resident workroom and pocket reminder cards were handed out. Finally, our screening efforts were discussed with the hospitalists to emphasize compliance with the resident teams. When each patient was admitted, residents asked about sexual activity and offered screening during the social history which is conducted without the parents.

Summary of Results

A total of 167 patients were included in the study. 120 patients in the pre-intervention group and 47 patients in the post-intervention group. The screening rates for GC/CT, HIV, and syphilis prior to the intervention were 17.5%, 22%, and 21% respectively. The screening rates for GC/CT, HIV, and syphilis following the third PDSA cycle were 45% (p<0.05), 36%, and 36% respectively.

Conclusions

Cumulative efforts to increase education for physicians and posting of visual cues improved STI screening rates. We demonstrated through our quality improvement project that screening rates for STIs can be improved in the hospital setting through simple and targeted education.

290 Always ask why – preventing delayed diagnosis and treatment

A Ahuja*

P Yedla

University of Alabama at Birmingham, Huntsville, AL and University of Alabama at Birmingham, Huntsville, AL

Case Report

Patient is a 69-year-old retired professor admitted to service for evaluation of extensive rash with multiple blisters, who was ultimately diagnosed with bullous pemphigoid. Patient had been bed-bound for the last two years without the issue being addressed. He was told he had diabetic neuropathy several years ago and gradually became non-ambulatory over a year. His physician advised him to follow up with his neurologist, but patient never made it due to transportation issues and poor social support system: his kids live out of town and he was having issues with his caregiver. Not satisfied with a diagnosis of diabetic neuropathy, we consulted neurology. Lumbar puncture and nerve conduction study confirmed chronic inflammatory demyelinating polyneuropathy (CIDP) & MRI of the cervical spine showed severe myelopathy. Patient had laminectomy and was discharged to acute rehab. 6 weeks later, patient was still unable to walk and had not finished IVIG treatments due to transportation issues.

Discussion

1) Social determinants of health (SDH) are the conditions in which people are born, work, and reside that influence conditions of daily life. These factors include education, neighborhoods, social support networks, and access to health care. As patients present in the hospital, we often treat the medical diagnoses and look no further. However, it is ineffective to care for a patient without addressing SDH as these pose significant obstacles to treatments. For a true patient-centered approach, we must screen our patients for any underlying burdens as this influences health outcomes. 2) Independent patients who are capable of activities of daily living can gradually become non-ambulatory after a hospitalization, a fall, or without any obvious reason in the outpatient setting. Many times, patients nor their families question as to why they are not returning to baseline status. As medical providers, it is our responsibility to question this for them. Do not assume all patients have been evaluated to the fullest extent or have received diagnoses for each presenting ailment. Asking our patient why he had not walked in a year lead to further questioning and initiated the CIDP diagnosis after workup was delayed for over a year.

291 A national study on prevalence and racial disparities in lung cancer screening

MU Alsaggaf1,2*

M Alghamdi3

M Anteet1

K Sigel4

1Ochsner Health System, New Orleans, LA

2King Abdulaziz University, Jeddah, Saudi Arabia

3Ministry of Health, Jeddah, Saudi Arabia

4Icahn School of Medicine at Mount Sinai, New York, NY

Purpose of Study

Evaluation and analysis of lung cancer screening uptake, and whether racial disparities exist using the 2017 survey of CDC Behavioral Risk Factor Surveillance System (BRFSS) for subjects who fit the US Preventive Services Task Force (USPSTF) criteria.

Methods Used

The BRFSS 2017 collected lung cancer screening data from ten US states (Florida, Georgia, Maryland, Missouri, Nevada, Oklahoma, Vermont, Wyoming, Kansas, and Maine). Individuals who fit the USPSTF lung cancer screening criteria were included in this study (smoke 30 pack/year, 55 to 80 years old, and current smokers or have quit within the past 15 years). The dependent variable is the computed-tomography lung cancer screening within the past year. Adjusted associations between the dependent variable and the independent variables were analyzed using multivariate logistic regression.

Summary of Results

A weighted total of 1,301,248 subjects who fit the USPSTF lung cancer screening criteria were included in the analysis. 18% of subjects were screened (see table 1), the percentage increased compared to the reported percentages (3–4%) in previous studies between 2010–2015. Racial disparities exist in lung cancer screening; the prevalence of screening in minorities was significantly less than Whites (Hispanic OR = 0.27, 95% CI 0.08–0.8) and Blacks OR = 0.28, 95% CI 0.09–0.84). Variables related to healthcare coverage showed a significant association with screenings, subjects without healthcare coverage had lesser odds of getting screening than those with coverage. Screening prevalence was different across included states; Florida had the highest uptake at 24%. On the other hand, Nevada had the lowest uptake at 11%.

Abstract 291 Table 1

Conclusions

The prevalence of lung cancer screening improved in 2017 compared to prior years, however, it is still low. Racial disparities exist among screened individuals, directed screening programs for racial minorities may be beneficial.

292 Key to becoming better antibiotic stewards for suspected urinary tract infections in children ≥2 years

ST Ansari1*

L Bradley2

1Children’s Hospital of Wisconsin, Brookfield, WI

2Children’s Hospital of Wisconsin, Milwaukee, WI

Purpose of Study

The American Academy of Pediatrics developed a guideline for the diagnosis and management of UTI in febrile infants in 2011.The age of majority of patients seen for suspected UTI at Children’s Wisconsin(CW) is >2 years.Also, a nitrite positive(NP) urinalysis(UA) is highly specific for UTI.Guidelines regarding initiation of empiric antibiotic(EA) therapy in children ≥2 years with a nitrite negative(NN) UA are not clear.Assess current state of EA prescribing practices for children ≥2 years of age with suspected UTI in NN and positive leukocyte esterase(LE) UA.

Methods Used

A retrospective chart review of patients aged 2–18 years who provided clean void urine specimens for suspected UTI from January to December 2019 and had paired UA & urine culture reports was performed.Patient demographics, documented/reported fever,UA results,urine culture report and EA therapy were obtained from electronic medical records.UTI was defined as urinary symptoms,pyuria on UA,and ≥50,000 colony forming units of uropathogen on urine culture report.Patients with a NP UA were excluded.

Summary of Results

1065 patients were included in the study(mean age 7.0 years, 89% female).135(12.7%)of all included patients met UTI criteria.349(32.8%)of 1065 patients had trace or 1+ LE on UA, of which 24(6.9%) met UTI criteria.116(33.2%)out of the 349 patients with trace or 1+ LE were started on EA for a suspected UTI,104(89.7%)of which did not meet UTI criteria.57(16.3%)of 349 patients had a temperature >38.0°C,of which 2(3.5%)met UTI criteria.

Abstract 292 Table 1

Urgent care POCT UA and urine culture predictive statistics

Conclusions

Initiating EA therapy for patients ≥2 years of age with trace or 1+ LE on UA resulted in overtreatment in 89.7% of cases.Fever was not a strong predictor of UTI in this group.Study findings suggest that providers can be better antibiotic stewards by waiting for the urine culture report prior to initiating EA therapy for patients with trace or 1+ LE and NN on UA.

293 Contribution of boarding time to emergency department overcrowding in an academic hospital

KE Anthony*

E Baus

Louisiana State University Health Sciences Center, New Orleans, LA

Purpose of Study

The Joint Commission recommends boarding time (defined as elapsed time between deciding to admit an ED patient and transferring said individual to an in-patient floor) should be limited to four hours. Prolonged boarding times contribute to ED overcrowding and decrease patient safety. Our study aimed to understand how University Medical Center’s ED boarding time compares to this recommendation and if encouraging ED physicians to submit an in-patient bed request prior to IM consult would expedite patient transfer to an inpatient floor.

Methods Used

The boarding time was calculated from the time that admission orders were entered into EMR to the time of transfer to an in-patient floor. Additional intervals were calculated based on other parameters noted: Time from Consultation to Transfer to In-patient Floor (1) and Hospital Bed Ready to Transfer to Inpatient Floor (2), and. Medical records of 1,185 patients were reviewed. 957 were placed in the control group. 228 patients had an in-patient bed request (IBPR) placed by the ED physicians.

Summary of Results

The average boarding was 4h 28m (95% CI 0h18m), exceeding the Joint Commission’s recommendation. There was no statistical difference between the boarding times of the IPBR and control group: 4h 24m (95% CI 0h26m) and 4h 29m (95% CI 0h22m), respectively. Despite this, the time interval designated (1) above was lower in patients with an IPBR than without (1h04m (06m) vs 1h36m (10m)). Though the IBPR aided in quicker admission of patients, this time-savings was not significant enough to affect the boarding time. Around 25% of the boarding time for all patients fell within the interval designated as (2) and was similar between the IPBR and control groups: 1h38m (08m) and 1h49m (17m).

Conclusions

We recommend further examination of the components contributing to UMCNO’s prolonged boarding times. While there should be continued collaboration between the IM and ED services, it is beneficial to account for the contribution of other ancillary staff (i.e. transportation, laboratory/radiology) to this time interval. Additionally, we plan to compare how boarding time varies with time of year. Similarly, since our original data collection, more hospital beds are available for inpatient use and we hope to quantify if there any impact on boarding time with this addition.

294 Racial injustice perceptions reawakened by the COVID-19 pandemic

MI Arrieta1,2*

LL Parker1

MD Carter1

RS Hanks1

ED Crook1,2

1University of South Alabama, Mobile, AL

2USA Health College of Medicine, Mobile, AL

Purpose of Study

Data shows minority communities experience profound impacts of disease severity and death if contracting COVID-19. We sought to understand the lived experience of the pandemic in an underserved, inner city minority community in Mobile County, AL.

Methods Used

This qualitative study gathered data via Focus Groups and Key Informant interviews with community members, leaders, or advocates. The analysis team implemented a deductive rapid analysis of scribe notes from eight data collection events. The data addressed twenty-six basic analysis questions.

Summary of Results

Issues of disparity, inequality, and racial bias were prominent in the discussions. Study participants stressed that African Americans have a long history of unequal and even harmful treatment from the healthcare system. This history means that many in the community are not surprised by the statistics of African Americans dying at a higher rate than whites. Community advocates are ‘curious’ about such reality and quizzical of why disparities persist in comorbidities that make the virus’ impact worse. Distrust and frustration may keep persons from going to the hospital (even if experiencing COVID-19 symptoms) for fear of receiving subpar treatment simply because they are Black.

The experiences of bias run deep in the African American communities’ understanding of the COVID-19 pandemic. Experiences of disparity, in particular health disparities, are a norm in the community, with one participant describing the situation as ‘another storm to be weathered.’

Throughout the research process, a few participants conveyed their sense of déjà vu. They had communicated the reality of their communities many times before. Where we focused the conversation on the COVID-19 pandemic, the issues of socioeconomic disadvantage, inequality, distrust, and structural racism would surface whatever the topic to be addressed.

Conclusions

Underserved African American communities experience sustained stress from inequality and injustice. The slow progression toward equity renders them vulnerable. It is necessary to address the fundamental drivers of inequity to foster resilience to any stressor, not just COVID-19.

295 Antivenom use or observation for patients with copperhead snake envenomation?

KS Baab1*

F Ramirez-Cueva2

A Larsen1

E Knowlton1

R Rainey-Kiehl1

A Hendrix1

M Condren1

M Woslager1

1The University of Oklahoma School of Community Medicine, Tulsa, OK

2Augusta University, Augusta, GA

Purpose of Study

Crotaline snake envenomation is a potentially serious medical condition affecting thousands of Americans each year. Snakes in the subfamily Crotalinae include, but are not limited to, copperheads, rattlesnakes, and cottonmouths. Variation in treatment of crotaline snakebites exists among physicians in the United States. In particular, managing copperhead snakebites is hypothesized to require minimal intervention, rarely requiring antivenom use and, even rarer, surgical intervention. This study assessed FabAV antivenom use and treatment outcomes for copperhead-envenomated patients in northeastern Oklahoma.

Methods Used

A retrospective cross-sectional review examined electronic medical records (EMR) of patients with venomous snake bites from July 1, 2014 to August 31, 2019. Patient demographics, snake species, clinical presentation and lab results were collected. Associations between patient variables and treatment were evaluated using the χ2, Median tests, and binary logistic regression.

Summary of Results

Of 256 patients meeting inclusion criteria, 139 were envenomated by a copperhead. Compared to patients under observation (no antivenom, n=42), those treated with antivenom (n=97) were more likely to have ICU stays (χ2(1)=29.5, p<0.001). Few patients under observation experienced complications requiring intervention (n=3, 7%) or ICU stays (n=2, 5%). For FabAV-treated patients, 17% experienced complications (n=16) and the majority had an ICU stay (n=54, 56%). Comparing the antivenom administered vs. observation cohorts, there were no statistically significant differences in the proportion of patients who were hemotoxic (χ2(1)=0.91, p=0.34), or in the number of systemic symptoms (χ2(1)=0.78, p=0.38). Progression of venom effects across major joints was significantly associated with FabAV treatment.

Conclusions

Hospital policy of administering antivenom in the ICU for adult patients may contribute to the association between ICU stay and antivenom treatment. For those patients with a copperhead snakebite, treatment by observation had favorable patient outcomes, including reduced chance of an ICU stay and reduced overall length of hospital stay.

296 Impact on the fitness of n95 masks with extended use/limited reuse, and heat decontamination

BC Bunch1*

M Zha2,3

J Alsarraj2

1Washington State University, Pullman, WA

2Columbia Basin Health Association, Othello, WA

3Mayo Clinic Research Minnesota, Othello, WA

Purpose of Study

To evaluate the respective and additive impact of extended use/limited reuse, and heat decontamination on the fitness of N95 masks, during the COVID-19 pandemic.

Methods Used

Twelve dental staff in a busy practice who recently passed the OSHA mandated fit test to wear the 3MTM 9211 masks participated. Before each 10-hour shift, volunteers obtained a new mask. A used mask was collected and a new mask obtained if the 10-hour shift is finished and the count of don/doff is less than 5 (‘extended use group’), or before a shift ends and the don/doff count reaches 5 (‘limited reuse group’). The mask was discarded if there is any obvious hardware failure. Fit test was performed on collected masks. High velocity hot air (HVHA) decontamination was done using a CPACTM RH-N95 unit for a full cycle. Masks were fitted again.

Summary of Results

167 new masks are used. After a 10-hour shift, if the CDC recommended 5 don/doff rule is adopted, the retention rate of N95 masks was 30.5%. If not, the retention rate is 82.6%. 83.3% of masks after limited reuse group, and 85.4% after extended use group. This is not a statistically significant difference (p=0.807). After one cycle of decontamination, the mask fitness of the limited reuse group is significantly reduced (p=0.002), and the mask fitness of the extended use group is not (p = 0.191).

Conclusions

Extended use/limited reuse are reasonable ways to preserve N95 masks in healthcare setting, and it may be safe to extend the count limit of don/doff to beyond 5. The combination of extended use/limited reuse with heat decontamination significantly

297 Improving documentation in an academic general pediatrics clinic

J Dannenberg1,2*

A Pope1

J Yaun1,2

1University of Tennessee Health Science Center, Memphis, TN

2Le Bonheur Children’s Hospital, Memphis, TN

Purpose of Study

Well child care (WCC) is a cornerstone of pediatric care. In addition to teaching clinical skills, educators must also teach documentation, billing, and coding as part of resident education. For the Tennessee Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, certain components must be documented in WCC notes. Some of these requirements include important health screenings and portions of the physical exam. We hypothesized that all required components of the EPSDT WCC were not being completed in our resident teaching practice. Our objective was to conduct a quality improvement to improve documentation.

Methods Used

Baseline data was collected from December 2019 to May 2020. Twenty charts of children ages 0 to 15 months presenting for WCC were randomly selected and reviewed for completion of selected EPSDT components, including screening for anemia, lead, tuberculosis, and hyperlipidemia risk factors, food insecurity screening, and performance of a complete physical exam. Using the plan, do, study, act method, specific interventions were implemented, including a new note template. Follow up data was reviewed for the next 6 months. The percentage of required components documented was recorded.

Summary of Results

Baseline data demonstrated that 45.2% of all measured items were documented in WCC notes. We aimed to improve documentation to 60.2% over the next 6 months. While our first intervention led to an increase in documentation of the EPSDT screening questions, overall documentation decreased to 36.2%, in large part due to dramatic decreases in documentation of food insecurity questions and required physical exam components.

Conclusions

While the first intervention led to increased screening for anemia, lead, tuberculosis, and hyperlipidemia risk factors, overall documentation rates decreased. The new note template is a work in progress and further interventions will include methods designed to increase the documentation of food insecurity screening and required physical exam components. Education on documentation requirements is ongoing and other methods are being implemented for improvement. Documentation, billing, and coding are all an important part of resident education.

298 Incorporating a point of care ultrasound course in a new internal medicine residency program

TC Do*

S Ganti

J Depa

Appalachian Regional Healthcare, Whitesburg, KY

Purpose of Study

The goal of this study is to evaluate the competency of internal medicine residents after a formal course of POCUS during orientation. ACGME requires POCUS training in emergency medicine residents but not for internal medicine residents. This study will be part of an evaluation of whether or not POCUS needs to be taught during orientation in an IM program and what needs to be in the curriculum based on residents’ feedback.

Methods Used

This was a prospective cohort study with 7 incoming interns. A pre-course survey determined the residents’ previous exposure to ultrasound. A competency checklist covering the application of ultrasound was used on a student volunteer model prior to the course. The checklist involved heart and lung evaluations in addition to viewing the internal jugular vein and carotid artery. A total of 15 objective written multiple choice questions and 7 ultrasound videos questions were made. The course was broken down into 2 sessions due to the scheduling. It consisted of a didactic session taught by a critical care physician who uses POCUS and then a hands on session of the application of ultrasound with the same physician on a different student volunteer model. The interns were reevaluated 6 weeks after the course using the same written and video assessment and competency checklist on a different student model. A post survey was used to obtain feedback from the residents.

Summary of Results

At baseline, the average on the written part was 43% while the video portion was 50%. The average on the application of POCUS was only 12%. 6 weeks after the course, the averages did improve. Although they rarely practiced using the ultrasound on their inpatients, the average of the application of POCUS was 78%. This was a drastic improvement compared to the written and video part. With the written part, the average increased to 61% while the video portion increased to 69%.

Conclusions

The interns agreed that the course was helpful but wanted more hands on sessions with the physician. The course was successful due to the increased averages. In order to further determine competency, the interns will be reassessed in 6 months to determine retention of POCUS. Although they didn’t practice much within the 6 weeks, it will be interesting to see what the outcome will be in 6 months.

299 Comparing two facilitator debriefing rubrics to assess post-simulation debreifings

N Guimbarda*

M Tews

Augusta University Health System, North Augusta, SC

Purpose of Study

The use of simulation-based learning in medical education is essential. Arguably the most critical feature of simulation-based learning is proper debriefing. Many educators have adopted the PEARLS model to guide their debriefing sessions in an effort in facilitate more effective and consistent learning with their students. The aim of this study was to determine if a debriefing rubric could be used to effectively measure facilitator adherence to the PEARLS model by analyzing video recordings of the facilitator’s debriefings.

Methods Used

Approximately 130 hours of student debriefings were analyzed. During the video review, researchers evaluated facilitator adherence to the PEARLS debriefing model using two different debriefing rubrics for each video. The debriefing rubrics were the Pearls Debriefing Checklist (PDC) and the Pearls Debriefing Adherence Rubric (PDAR). Inter-rater reliability was established with an interclass correlation coefficient, and the reliability of the results of the two instruments were calculated using Cronbach’s alpha. Pearson’s correlation was calculated as evidence of convergent validity of the two instruments.

Summary of Results

The inter-rater reliability for the sum of scores for the PDC, PDAR, and total scores for both tools combined demonstrated an acceptable level of agreement. Measures of internal consistency for the PDAR and PDC were .515 and .714 respectively. A Pearson correlation of .648 was calculated for the convergent validity between sum of the debriefing scores tor both tools.

Conclusions

Since there was a lack of compelling evidence of both consistency and convergent validity for each of the instruments, this study demonstrates that there is additional work necessary in the evaluation of faculty debriefing behaviors. This study posed a difficult challenge, which was to find a way to operationalize and quantify observed behaviors. The two debriefing adherence rubrics used in this study were based on standardized facilitator behaviors that may not be applicable to all debriefings universally. The best use of the PDAR or PDC in their current iterations would be by simulation program administrators looking to provide formative feedback to novice facilitators in the effort to maximize student learning in the medical setting.

300 Standardization of maintenance intravenous fluids in pediatric inpatients

J He*

F Litra

CR Antonetti

University of Florida, Pensacola, FL

Purpose of Study

To locally implement the 2018 American Academy of Pediatrics (AAP) Clinical Practice Guidelines: Maintenance Intravenous (IV) Fluids in Children to increase proportion of patient hospital days with exclusive isotonic IV fluid use to ≥ 80%.

Methods Used

Our academic-affiliated, community-based children’s hospital participated in a national quality improvement project with the AAP Value in Inpatient Pediatrics Network, ‘Standardization of Fluids in Inpatient Settings.’ AAP IRB approval was obtained. Table 1 lists inclusion and exclusion criteria. 15 months of baseline type and duration of IV fluid use at our center was collected by retrospective chart review. A fluid management algorithm, lecture, and electronic medical record (EMR) order set were implemented in September 2019 (cycle 16). Nine months of post-intervention data were collected. Post-intervention isotonic IV fluid use was compared to baseline use via Z-test.

Summary of Results

206 baseline and 170 post-intervention charts were reviewed. Baseline isotonic IV fluid use varied from 47.62% to 100%, and became consistent between 82.14% to 100% following intervention (figure 1). Proportion of exclusive isotonic fluid use in the baseline group was 78% (95% CI 72–83%), compared to 93% (95% CI 89–97%) in the post-intervention group, p< 0.001.

Abstract 300 Table 1

Patient inclusion and exclusion criteria

Abstract 300 Figure 1

Proportion of patient hospital days with exclusive isotonic IVF use at our hospital

Conclusions

This quality improvement project shows that educational and EMR interventions can standardize the use of isotonic fluids in pediatric inpatients in accordance with AAP guidelines.

301 A campus wellness inventory for students and employees

N Khorsandi*

S Embley

M Bishop-Baier

LSUHSC-New Orleans, New Orleans, LA

Purpose of Study

University wellness programs target health-related goals for staff and students such as physical activity, nutrition, and mental health. Programming improves individual health and wellness as well as improves productivity, campus morale, staff and student relationships, and decreases absences. To maximize utility of the Louisiana State University Health Sciences Center-New Orleans’ (LSUHSC-NO) current wellness programming, the Wellness Inventory for Students and Employees (WISE) was created. WISE assesses satisfaction and awareness of campus wellness initiatives and garners feedback on how programming can be improved.

Methods Used

WISE is a 23-question quantitative survey with qualitative components that targeted current LSUHSC-NO wellness programs: cafeteria, campus gym, on- and off-campus counseling, Tobacco-Free Campus Initiative, and campus lactation rooms. The quantitative aspect employed a 5-point Likert scale of agreement assessing respondent satisfaction and awareness levels. Qualitative data was analyzed to identify common themes in responses for improvement opportunities of campus wellness programming.

Summary of Results

939 of 7,000 (13%) LSUHSC-NO staff and students responded to the WISE. The three highest areas of agreement were: campus-wide tobacco policy awareness (97%), gym equipment availability (87%), and on-campus counseling assistance awareness (83%). The three lowest areas of agreement among participants were: on-campus lactation rooms satisfaction (9%), state tobacco quit-line awareness (18%), and off-campus counseling cost (25%). Qualitative results identified a total of nine areas of strengths and nineteen opportunities for improvement in programming.

Conclusions

The high response rate of 13% (compared to previous campus-wide surveys) for the WISE indicates a general interest of campus staff and students to improve wellness programs. Through this assessment, campus wellness staff have been able to highlight programs’ areas of strength and improve areas of weakness. There are also many areas identified from qualitative comments that will need further exploration by the wellness committee and staff. Continued iterations of the WISE will be necessary for LSUHSC-NO to optimize wellness programing for staff and students.

302 Flu vaccination rates of documentation during flu season

N Lalchandani1,2*

C James1,2

S Sarkar1,2

1LSU New Orleans, New Orleans, LA

2Children’s Hospital New Orleans, New Orleans, LA

Purpose of Study

Our aim is the increase the rate of influenza vaccination documentation during flu season by residents by 25% in the next 2 months, piloted on the 5th floor unit for general pediatrics patients.

Children under the age of 5 are particularly high risk of serious complications of influenza. Many children that are admitted to the hospital also have chronic conditions including asthma, diabetes or an immunocompromised state. The goal of this project is to assess documentation rates of the flu vaccination (FV) through nursing and medical provider notes. Every patient that is admitted to the hospital should be assessed if they have received the flu vaccination for that flu season. Residents and physicians should be knowledgeable and prepared to educate families especially common misconceptions about flu shots. If the patient has not received flu shot, they should receive flu vaccination prior to discharge.

Methods Used

Primary Outcome: Rate of documentation

Secondary Outcome: Flu vaccination rate

Process: Rate of documentation of those that did not document

Summary of Results

Rates of FV documentation were higher with nurses compared to residents in both the 2018–2019 and 2019–2020 flu season. After intervention #1, there was a small increase in documentation. A greater increase of documentation was seen after intervention #2. Although we saw improvement in the primary outcome, it is uncertain if those unvaccinated patients received the FV prior to discharge. We can look retrospectively to see if those patients that had been unvaccinated were vaccinated before discharge. Nurse driven protocol for FV administration or building the FV into a discharge order set are future considerations.

Abstract 302 Table 1

Rate of documentation

Conclusions

All children over the age of 6 months should receive the FV. This is the most effective way to protect them from having serious flu-related complications as well as protect our communities. We should ensure that every child who is eligible to receive the FV has the opportunity to do so.

303 Childhood obesity in primary care project – memphis site

MK McEwen*

A Walsh

MM Vickers

S Martinez

A Breithaupt

A Montague

A Broadnax

R Assfoura

J Yaun

N Bishop

M Hare

A Odulana

LBonheur Children’s Hospital, Memphis, TN

Purpose of Study

The ULPS General Pediatrics Clinic was a part of the Childhood Obesity in Primary Care Project (COPC), a quality improvement project intended to improve the implementation of comprehensive obesity-related health risk assessment in pediatric primary care practices. Aims were: 1) Assess obesity risk, including an assessment of growth, 50% of the time for patients < 2 years of age and 85% of the time for patients from 2 - 21 years of age; 2) Assess and counsel on healthy active living (HAL) behaviors 50% of the time for patients from 2 - 21 years of age; and 3) For overweight or obese patients, assess medical risk (through Family History (FH), obesity Review of Systems (ROS), and Physical Exam (PE)) 50% of the time and, when indicated, provide appropriate follow-up through lab orders and work-ups 50% of the time.

Methods Used

We conducted retrospective chart reviews (n=120) on Well Child Checks during three time periods in 2018 and 2019. Forty records were reviewed per cycle using a de-identified data collection sheet and then entered into the AAP’s Quality Improvement Data Aggregator, producing clinic reports on grouped data. After each cycle we used the clinic reports to assess how well our clinic performed compared to the aims and to identify areas for improvement. To improve our documentation of obesity-specific FH and ROS, we created a FH form for parents to fill out and updated our electronic ROS.

Summary of Results

The percentage of appropriate documentation of FH and ROS increased from 7% to 20% to 41% and 20% to 30% to 67%, respectively. Additionally, appropriate documentation of HAL rose from 43% to 64% to 72% and appropriate PE documentation rose from 20% to 70% to 67%.

Conclusions

The results of the ULPS General Pediatric Clinic’s data from participation in the COPC Project led to improvement in gathering obesity specific FH and ROS. Additionally, improvements were made in HAL and PE documentation. As a result of our findings, the clinic designed a new Healthy Weight Visit Note to assist in improving obesity relevant documentation during dedicated weight visits. In addition, our team is developing a new healthy weight curriculum to train residents about obesity management in the primary care setting.

304 Healthcare workforce diversity: pipeline programs’ role

R Nabaweesi*

K Blann

N Pettus

G Richard-Davis

University of Arkansas, Little Rock, AR

Purpose of Study

Assess summer pipeline programs performance in reaching and preparing under represented minority students for science, technology, engineering, mathematics and health careers.

Methods Used

Junior STEM Academy (JSA) targets K-3 and Senior STEM Academy grades 46. Scholars are immersed in health science while incorporating technology, engineering, and mathematics (STEM-H). Academy uses a combination of effective teaching pedagogies to design a culturally responsive and holistic curriculum, including didactic and hands on learning approaches.

Academy of Pre-Health Scholars (APHS): 5-week program pairs high school students with health care leaders to learn about biomedical sciences, research and public health. It also introduces them to career pathways in health care and helps them prepare for the ACT college entrance exam.

Pre-Medical Summer Scholars (PMSS) prepares undergraduate students interested in medical school for the MCAT entrance exam. The six-week program involves direct instruction, workshops to teach scientific knowledge and application in critical thinking and writing.

Summer Research Internship (SRI): Outstanding undergraduate and select high school URM students engage in in-depth faculty-mentored scientific research. Participants present research findings using posters.

Summary of Results

In FY 2020, 212 served students (200 Black and 12 Hispanic) from low social economic families, as determined by school lunch eligibility. Mean participation was 150, 25, 20 and 20 for STEM Academy, APHS, PMSS and SRI respectively. JSA and SSA participants reported high self-efficacy and confidence in pursuing Science, Technology, Engineering, Mathematics and Health (STEM-H) programs, better positioning them to pursue careers in health sciences.

98% APHS participants had a 2–4 year college attendance rate and, 100% CPR and First Aid certification. All APHS participants reported increased confidence in pursuing an undergraduate major in STEM-H with increased awareness of careers and educational opportunities beyond medical doctor. Mean pre-post MCAT change was 5.8. All SRI students complete and present a research project.

Conclusions

STEM academy and APHS are effective at supporting URM students. Formative evaluation will identify barriers and facilitators for URM students improved MCAT performance.

305 Community health programming models target influenza disparity reduction in African Americans in New Orleans, LA

S Nedunchezhian1*

DP Ferdinand2

K Ferdinand2

1Tulane University School of Medicine, New Orleans, LA

2Healthy Heart Community Prevention Project, New Orleans, LA

Purpose of Study

Healthy Heart Community Prevention Project, Inc. (HHCPP), a New Orleans community health organization, along with Sustainable Healthy Communities (SHC), LLC, organized an influenza education program during the 2019 and 2020 influenza seasons. The pilot program utilized community health programming in vulnerable New Orleans communities to disseminate culturally and clinically validated cardiovascular disease (CVD) information, emphasize social determinants of health on influenza and CVD, and educate on the benefits of flu vaccination.

Methods Used

Zip codes with predominantly African American populations and high prevalence of diabetes and CVD comorbidities were identified via geospatial analysis. Community and faith centers were chosen to bolster community-centered health education, improve participant self-efficacy, and increase accessibility. Two physicians, Keith C. Ferdinand, MD and Bo Nebolisa, MD, hosted health seminars on influenza disparities and distributed non-commercial clinical health materials. Pre and post-seminar surveys assessing education and retention of health information were administered. Primary data collected via sign-in sheets, surveys, and participant testimonials were analyzed using SPSS statistics and Microsoft Excel.

Summary of Results

Programs were completed at two community centers, five faith centers, two senior homes, and a local community hospital during both seasons. Data analysis demonstrated increased participant ability to identify multiple barriers to and health benefits of influenza vaccination. Moreover, increased engagement was noted when seminars were coupled with health materials and incentives.

Conclusions

The HHCPP demonstrated positive impact of utilizing community partners and local minority health advocates in trust building, action, and accountability towards reducing longstanding health disparities. Limitations include: COVID-19 pandemic restricted program completion during the 2019 season and participant hesitation to divulge personal residence zip codes. Future program directions include zip code-driven diabetes risk reduction, health belief model workshops to overcome belief barriers, and faith and community leader involvement to support influenza education initiatives.

306 Common sports injuries in children presenting to emergency department: a single institution retrospective review

J Nichols*

A Sorrentino

NP Shah

K Monroe

University of Alabama, Birmingham, AL

Purpose of Study

Participation in sports is popular among children and a common cause of pediatric injury. Understanding the epidemiology and trends of sports related injuries is an important component of injury prevention efforts.

Methods Used

A retrospective review of sports injuries presenting over one year (2019) to an Emergency Department (ED) of a large academic Children’s Hospital was performed. Inclusion criteria focused on patients ≤ 18 years whose ED visit resulted from active participation in a sport. Cases were identified using ICD-10 codes. Demographic data was collected on these patients and included gender, age, race, injury specifics. Descriptive statistics were performed and categorical variables were analyzed using chi-square test.

Summary of Results

A total of 1333 sports injuries were identified with the most common being football (43%); basketball (36%); soccer (11%),baseball (8%). The median age was 13 years (IQR: 4 years), 428 (32%) < 12 years and 905 (68%) ≥ 12 years; 1143 (86%) were males and 835 (63%) were black. School was the most common location for sports injuries (28%). When comparing injuries by age groups (<12 vs. ≥12), baseball and football injuries were more common in those < 12 years (14% vs.6% and 53% vs. 38% respectively) whereas basketball and soccer injuries were more common in those ≥12 (43% vs 22% and 11% vs 9% respectively); p<0.001. When comparing injuries by gender, baseball and football injuries were more common in males (9% vs. 2% and 49% vs. 6% respectively) whereas basketball and soccer injuries were more common in females (59% vs 32% and 27% vs 8% respectively); p<0.001.

Conclusions

Sports injuries that are commonly encountered in the emergency department differ in age and gender. Basketball and soccer injuries were more likely to be encountered in older females, while baseball and football injuries were more likely seen in younger males. This information can help guide future preventative efforts provided by primary physicians, schools, and coaches.

307 Recreational mobility vehicles and pediatric injuries

J Nichols1*

A Sorrentino2

NP Shah2

K Monroe2

1University of Alabama, Birmingham, AL

2University of Alabama School of Medicine, Birmingham, AL

Purpose of Study

Injuries are the number one cause of death in children and cause significant morbidity. Common scenarios for injury include vehicles that allow children to be mobile and independent (example ATV- all terrain vehicles, dirt bikes, bicycles, skateboards, and scooters). We present a case series review of these external causes of injury.

Methods Used

Following IRB approval, the electronic medical record was queried to identify all patients with an injury related to a recreational vehicle during a one year period (2019). Demographics with injury specific (body part injured, site where injury occurred, mechanism) and helmet usage were collected and analyzed using Excel. Patterns of injury and ages at risk are highlighted

Summary of Results

A total of 246 patients were identified (104 bicycle, 74 ATV, 25 dirt bike, 14 motorcycle, 16 scooter and 14 skateboard). Ages ranged from 2 y to 18 years with the greatest range noted for bicycles (2 to 17 years) and ATVs (2 to 16 years). The mean age was higher for motorcycle and skateboard (13 and 11.6 respectively) and lowest for bicycle (9). Many of the injuries were to passengers (most of which are not designed to carry passengers). The majority of (overall study (97%) and for each mode of transportation) patients were Caucasian which is in contrast to our overall ED population, ( 42% Caucasian). The majority were male (n=181 (74%)). 140 of the 246 (57%) were not wearing a helmet ( 60% of ATV riders andl 5 patients who reported their helmet came off). The lowest percentage of riders reporting appropriate helmet use was skateboarders with only 14% wearing helmets, and the highest percentage was dirt bike riders with 80% reporting helmet use.

Conclusions

Common scenarios for injury include vehicles that allow children to be mobile and independent. Most of these injuries were found in Caucasian males between the ages of 9–12 with low rates of helmet use. It is no surprise that the study found many pediatric patients to be injured on these vehicles because most are not designed to carry passengers.

308 Resident morbidity and mortality conference

E Poindexter*

L Bittles

SE Hudson

J Cassady

C Cordes

S Walley

University of Alabama at Birmingham, Homewood, AL

Purpose of Study

Medical errors are increasingly recognized as a significant cause of patient morbidity and mortality (M&M). Given the potential for systems-based improvements through discussion of patient safety events (PSE), a need was identified for a formal M&M conference system within the UAB/CoA Pediatric Residency Program in order to help promote resident involvement in these processes. From 7/1/2020 – 7/1/2021 we aim to decrease the number of patient safety events at CoA by 20% compared to the preceding 12 month period (7/1/2019 – 7/1/2020). Given there were 18 PSE from 7/1/2019 – 7/1/2020, our aim is less than 14.

Methods Used

Each quarter, an hour-long case presentation is completed during residency noon-conference. During this time, a safety event is reviewed, utilizing standard SBAR format (situation, background, assessment, recommendation). Patient history and preceding information is discussed, followed by completion of an analysis of contributing factors and literature review. Resident leaders will then identify potential interventions to pursue (i.e. policy changes, areas for improved communication, mock codes, etc.). We will analyze the number of PSEs distributed quarterly to determine effectiveness of the M&M model as a quality improvement initiative.

Summary of Results

There has been one quarterly M&M conference since 7/1/2020. The number of PSE for Q3 of 2020 has not been released. There were 18 PSE between 7/1/2019 – 7/1/2020. Over the past 6 months, there has been a 50% reduction in PSE in comparison to the preceding 6 months.

Conclusions

We are encouraged by the data from last year and hope through thoughtful M&M conferences we can continue to engage residents in identifying problems and improving systems.

309 Erythrodermic psoriasis: fatal psoriasis and urgent recognition

C Rodriguez Negron*

Hospital Municipio de San Juan, Guaynabo, Puerto Rico

Case Report

Psoriasis a chronic inflammatory condition of the skin that occurs in around 2–3% of the population. Erythrodermic psoriasis (EP) is an extremely rare variant been the clinical hallmark a generalized erythema of the skin involving 75% of body surface area. Despite the availability of multiple therapies, mortality rates still range from 9–64%. Therefore, prompt recognition of this life-threatening condition is crucial to ensure early therapy and disease control. We present an uncommon case of EP manifesting in a Hispanic patient, which has been rarely described in the literature.

73 yo male with a history of HTN, Psoriasis, and alcoholism presented with the complaint of severe skin tenderness and eruptions of two weeks of progression until it started compromising body movements and oral intake. He stated he has been following a poor diet and consuming excessive alcohol for three weeks before visiting the hospital. Physical examination evident for severe desquamative skin, hard plaques, erythrodermic thick scales, and skin exfoliation, involving 80% of the body surface area. Lesions spare mucosa but present in the rest of his body, palms, soles, and genitalia. Laboratory show elevated creatinine and low bicarbonate, suggestive of severe dehydration. Also, present fever, tachycardia, and minimal body motion with exquisite pain. Biopsy with pathological findings suggestive of a psoriatic form of dermatitis. Immediately managed with IV Fluids, Antibiotics, and topical triamcinolone. However, 48 hours after admission patient developed septic shock, resulting in fatality.

Erythrodermic Psoriasis‘ critical situation is the severe capillary leak that develops due to loss of skin integrity with progressive edema, hypotension, superimpose infections, and subsequently high risk of fatality. There may risk factors that can provoke this psoriasis exacerbation including infections smokers, alcohol abusers among others. Sudden development of this skin inflammatory exacerbation requires an emergent diagnosis due to a high risk of systematic compromise that can succumb to multiorgan failure and severe cardiovascular compromise. This case illustrates the possibility of the 3% of psoriasis that can develop life-threatening situations and need urgent recognition in order to provide immediate therapy and avoid undesired outcomes.

310 The prevelance of low back pain and evaluation of prevention strategies amnog the electrophysiology and catheterization laboratory community (physicians, nurses, technicians) in rural hospitals

K Sawalha1*

N Beresic2

S Khan1

R Kamoga1

1White River Health System, Batesville, AR

2University of North Carolina System, Chapel Hill, NC

Purpose of Study

The objective of this study was to determine the prevalence of low back pain in rural community EP and Cath laboratories and the significance of exercise and physical activity routines, health education, and continued management support as low back pain prevention strategies in the EP/Cath lab community.

Methods Used

A cross-sectional survey was conducted utilizing 30 employees working in the EP/Cath lab from two rural hospitals. Informed consent was obtained. Investigators were blinded to identity of samples as the surveys were filled anonymously.

Summary of Results

  1. The largest group of subjects reports low back pain in L4–S1 area.

  2. This study showed a higher overall pervasiveness of low back pain but less low back pain symptoms on the short–term basis.

  3. The data showed an increase in the prevalence of low back pain once five years of service in an EP/Cath lab setting has been completed.

Conclusions

The primary goal of this study was to illustrate the prevalence and generalized characteristics of back pain among EP and Cath laboratories in rural hospital settings. Conclusions that may be drawn from this study are: the prevalence of low back pain demonstrated within this study were consistent when compared to available studies, low back pain is a common condition among EP and Cath lab employees, and several low cost/low risk preventative strategies for reducing musculoskeletal symptoms in the workforce are not currently being completed by those who participated in the study.

311 Cannabis-related emergency department visits in California since its legalization in 2018

N Shivaprakash1,2*

T Modi3

G Green1

1California University of Science and Medicine, Colton, CA

2Riverside University Health System, Riverside, CA

3Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Colorado was the first state to legalize and implement recreational cannabis in 2014. Since 2014, research has suggested an increase in patients with cannabis-related primary diagnoses in emergency departments (ED). California joined the list of states legalizing recreational cannabis in 2018 and we aim to explore its implications by looking at cannabis-related ED visits in California, before, during, and after the years of cannabis legalization.

Methods Used

To assess our hypothesis, we are conducting a cross-sectional, observational study using cannabis-related diagnoses data from the Colorado Hospital Association (CHA) and California Health and Human Services (CHHS) Hospital ED open datasets. A simple linear regression was done in order to assess any trend cannabis-related ED diagnoses might have had over time. In order to further understand cannabis-related ED diagnoses over time and the factors that might impact this, we constructed a binomial logistic regression model. This model was built using Colorado as a framework and aid in inferring, comparing, and interpreting trends in California.

Summary of Results

A strong, positive linear relationship of cannabis-related ED visits over time was observed in both Colorado from 2011–2017 (R=0.93) and California from 2014–2018 (R=0.99). Our model yielded two significant predictor variables in both states, (1) year(2013) in Colorado and year(2017) in California, and (2) the ‘new’ concept of the legalization of recreational cannabis. This indicates that although the number of cannabis-related ED diagnoses is increasing over time, the anticipation of, the actual legalization of, and the novelty of cannabis plays a role.

Conclusions

We investigated the impact cannabis legalization had on cannabis-related ED primary diagnoses overtime in Colorado and California. Our analyses provide a better understanding of the factors that may contribute to this trend and draw connections to public health implications previous literature has established. Our model can be used to predict the impact that the legalization of cannabis may have on emergency departments and, perhaps, begin the discussion on changes or adjustments that need to be made accordingly.

312 Psychotic and anxiety disorders presenting with cannabis use in California

N Shivaprakash1*

T Modi2

1Riverside University Health System, Riverside, CA

2Texas Tech University Health Sciences Center, Lubbock, TX

Purpose of Study

Cannabis legalization coincides with a decrease in the perceived harmfulness and can lead to increased improper use. Thus, there is a need for insight into the short and long-term mental and physical health impacts of cannabis. The largest increases were seen in persons who also had diagnoses of schizophrenia and other psychotic disorders, suicide or intentional self harm, and mood disorders. In 2018, the highest number of cannabis consumers in the United States were located in the state of California, amounting to approximately 5.9 million. In 2018, California also joined the growing list of states legalizing recreational cannabis. Therefore, there is a need to establish protocol and examine the patterns of patients receiving cannabis use, abuse, and dependence with psychotic or anxiety disorder diagnoses in California emergency departments to better help these patients and provide improved mental healthcare to this rising patient population.

Methods Used

In order to assess our aim and hypothesis, we collected cannabis with psychotic or anxiety disorder diagnosis data using ICD-10 codes from 2015 through 2018 from the California Health and Human Services (CHHS) Hospital ED open datasets. A simple linear regression was done in order to observe any trend cannabis with psychotic or anxiety disorder diagnoses assess might have had over time.

Summary of Results

According to our simple linear regression, cannabis with psychotic or anxiety disorder diagnoses in the ED has continued to increase over time (2015–2018) with a strong, uphill linear relationship (R= 0.87).

Conclusions

There are many complications related to cannabis use with acute mental illness, cannabis toxicity, cannabinoid hyperemesis syndrome, and cardiovascular complications. With the increase in cannabis use with psychotic or anxiety disorder ED diagnoses, it would be socially and economically beneficial to develop therapies to reduce the time spent in emergency departments and the number of hospitalizations due to improper use. This research highlights the increase in psychiatric diagnoses associated with cannabis-related ED visits, especially in states where recreational cannabis is legalized, and the significant need for data collection regarding cannabis dosing, side effects, and treatment protocol.

313 Increasing resident knowledge of an institutional pediatric palliative care team

MP Singh*

J Winer

MJ Cunningham

The University of Tennessee Health Science Center College of Medicine, Memphis, TN

Purpose of Study

Pediatric Palliative Care (PPC) was approved as an academic subspecialty in 2006 and remains an emerging subspecialty. E