Acute Aortic Thrombus with Splenic Infarction in a Patient with COVID-19 Infection

Acute Aortic thrombus with splenic infarction is a rare complication of COVID-19. This manuscript highlights the importance of early identification of this complication with abdominal imaging and early initiation of anticoagulation despite moderate severity of the disease.

Abdominal Imaging Utilization during the First COVID-19 Surge and Utility of Abdominal MRI

We sought to determine relative utilization of abdominal imaging modalities in coronavirus disease 2019 (COVID-19) patients at a single institution during the first surge and evaluate whether abdominal magnetic resonance imaging (MRI) changed diagnosis and management. 1107 COVID-19 patients who had abdominal imaging were analyzed for modality and imaging setting. Patients who underwent abdominal MRI were reviewed to determine impact on management. Of 2259 examinations, 80% were inpatient, 14% were emergency, and 6% were outpatient consisting of 55% radiograph (XR), 31% computed tomography (CT), 13% ultrasound (US), and 0.6% MRI. Among 1107 patients, abdominal MRI was performed in 12 within 100 days of positive SARS-CoV-2 PCR. Indications were unrelated to COVID-19 in 75% while MRI was performed for workup of acute liver dysfunction in 25%. In 1 of 12 patients, MRI resulted in change to management unrelated to COVID-19 diagnosis. During the first surge of COVID-19 at one institution, the most common abdominal imaging examinations were radiographs and CT followed by ultrasound with the majority being performed as inpatients. Future COVID-19 surges may place disproportionate demands on inpatient abdominal radiography and CT resources. Abdominal MRI was rarely performed and did not lead to change in diagnosis or management related to COVID-19 but needs higher patient numbers for accurate assessment of utility.

Abdominal and pelvic imaging findings in COVID-19

Pulmonary imaging findings of Coronavirus disease 2019 (COVID-19) has been widely described, but recently few studies have been published about abdominal and pelvic radiological presentation. The aim of this study was to provide an overview of abdominal imaging findings in patients with COVID-19. After investigation of recent published literature we came to conclusion that most common findings are associated with gastrointestinal abnormalities with mural thickening of part of gastrointestinal tract being the most common, followed by vascular and less frequently described solid organ and gallbladder abnormalities. It is important to be familiar with abdominal COVID-19 manifestations, since they’re often implicated with the development of poor clinical outcomes.

Relevance of Routine Abdominopelvic Ultrasound in Suspected Child Abuse in Children Under 2 years of Age: Review of 15 years of Experience

In France, the current recommendation is to perform a routine abdominopelvic ultrasound in any child under 2 years of age who is suspected to have been abused. We retrospectively studied the relevance of this practice in our center over the past fifteen years. This was a descriptive, retrospective study of all children under 2 years of age who had been subject to suspected abuse. Abdominal images and reports were reviewed and cross-referenced with possible clinical and biological signs. Four hundred and five children were included between 2006 and 2020, of whom 296 underwent abdominal imaging (2 initial abdominopelvic CT scans, 4 ultrasounds followed by CT scans, and 290 ultrasounds alone). Four examinations revealed traumatic abnormalities related to abuse. These four children all had clinical or biological anomalies. In the absence of clinical or biological signs, no imagery showed any abnormality related to abuse.

Geographic Remoteness Is Associated with Increased Blood Product Utilization and Higher Rates of Hospitalization and Deaths in Adults with Immune Thrombocytopenia

INTRODUCTION Immune thrombocytopenia (ITP) is a hematological disease characterized by immune-mediated destruction of platelets. Prior to starting therapy for ITP it is critical to determine whether it is idiopathic or related to a secondary underlying condition as this informs treatment. There is significant use of blood products and components in patients with chronic ITP for management of thrombocytopenia and bleeding, including intravenous immune globulin (IVIg). Platelet transfusions are generally reserved for life-threatening bleeding or may be used in the preoperative setting in patients unresponsive to other therapies. The aims of this study are to identify gaps in process of care and to examine the impact of geographical remoteness on health service utilization and outcomes in adults with chronic ITP in Alberta. METHODS Adults who received rituximab, splenectomy, or thrombopoietin receptor agonists (TPO-RA) as second-line therapy for ITP during 2012-2019 in the province of Alberta, Canada were identified via the provincial special drug access database. Diagnostic workup including bone marrow biopsy results, abdominal imaging (ultrasound or CT scan), coagulation parameters, viral serologies for hepatitis, human immunodeficiency virus (HIV), serum protein electrophoresis (SPEP), and quantitative immunoglobulins were recorded and rates of completed tests were calculated. Utilization of IVIg, platelets, and packed red blood cells was assessed. Rates of hospitalization, mortality, and ITP-related deaths were calculated and compared according to geographic region. RESULTS Of the 204 patients identified for analysis 106 were female (52%). Most patients (123; 60%) lived within a major centre, whereas 21 (10%) lived over 250 km from a major centre. Review of diagnostic laboratory parameters revealed incomplete coagulation parameters in 117 patients (58%), and no coagulation parameters checked in 16%. Eighty-nine patients (44%) did not have quantitative immunoglobulins tested, and 57 (28%) did not have an SPEP performed. Fifty-three (26%) did not have any abdominal imaging performed to assess for splenomegaly or liver disease. Thirty-five (17%) did not have any viral serologies for hepatitis B, C, or HIV completed. Bone marrow aspirate and biopsy was performed in 110 patients (54%). Eighty-six (77%) of these biopsies yielded a normal result. Eight biopsies (7%) displayed a lymphoproliferative disorder or plasma cell disorder which was suspected or known prior to completing the test. There was significant geographic discrepancy in utilization of blood products and hospitalizations. During 527 patient years of follow up, 83 patients received a total of 343 doses of platelets. Eleven patients (13%) received platelet transfusions for inappropriate indications, and eight (9%) for unclear indications. One hundred twenty-seven patients received IVIg (mean 1290 g) with comparable usage across geographic regions. Compared to patients within 250 km from a major centre, those with geographic remoteness (>250 km from a major centre) utilized more platelets (mean 5.2 vs 1.2 doses; Figure 1) and packed red blood cells (mean 4.3 vs 1.2 units; Figure 2). Those with geographic remoteness also experienced a higher rate of ITP-related hospitalizations (mean 1.5 vs 1.1) and deaths (24% versus 9%). At a median follow-up of 3.42 years from ITP diagnosis, 27 patients (13%) were deceased. Fourteen of these deaths were ITP-related due to bleeding or infection (52%). There appears to be a gradient of rates of both all-cause and ITP-related deaths by distance from a major centre (Figures 3 and 4). DISCUSSION This study highlights gaps in quality of care in patients with chronic ITP in Alberta, Canada. A significant number of patients have an incomplete workup for ITP at the time of diagnosis with the most forgotten tests being coagulation studies, SPEP, quantitative immunoglobulins, viral serologies, and abdominal imaging. Additionally, we identified an unexpectedly high rate of bone marrow biopsies performed in our population. Most of these bone marrow examinations did not result in any change in management. Finally, this study identified that geographic remoteness is associated with increased health services utilization and ITP-related deaths. These data can be used to inform further quality improvement initiatives in chronic ITP and help address geographic inequities in healthcare outcomes. Figure 1 Figure 1. Disclosures Sun: Bayer: Consultancy; Novo Nordisk: Consultancy; Pfizer: Consultancy; Shire: Consultancy; Octapharma: Consultancy, Research Funding.

The Increased Use of Diagnostic Studies over Time in Acute Myelogenous Leukemia Patients

Background: Guidelines on the clinical management of certain disease processes assists providers in their decision making and in some cases reduce the amount of further testing/imaging that a patient undergoes. Without evidence based guidelines in place, the medical provider relies on previous experience and their clinical judgement in pursuing additional diagnostic studies. In this observational retrospective descriptive analysis, we reviewed 188 inpatient Acute Myelogenous Leukemia (AML) patients between 2002 and 2019 who post-induction presented with objective abdominal symptoms and/or abnormal gastrointestinal laboratory values, as well as correlating the number of diagnostic imaging performed. Methods: Data was collected retrospectively from an academic medical hospital database for descriptive analysis. Patients included in the study were those diagnosed with AML between April 2002 and October 2019, underwent induction therapy (i.e 7+3 induction with Idarubicin), and who received abdominal imaging ultrasound or computed tomography (US/CT) within 40 days post induction therapy. Patients who underwent induction therapy between April 2002 and December 2010 was one group, January 2011-October 2019 was the other group. Only the first abdominal image performed with each patient within 40 days post induction therapy was included in our analysis. Individuals who were noted to have cholecystectomies, those without clear induction dates and patients under the age of 16 were excluded whether or not they received abdominal imaging. Access to test result databases are password protected. Results from each subject are codified based on their sample ID and are not traceable to any identifiable subject name. Results: 76 individuals had induction therapy initiation dates listed that were within April 2002-December 2010. Of those 76, 16 received abdominal imaging: 12 CT abdomen and 5 abdominal ultrasound. 112 individuals had induction therapy initiation dates listed that were within January 2011 and October 2019. Of those 112, 35 received abdominal imaging: 15 CT abdomen and 20 abdominal ultrasound. Compared to the latter 9 years in regards to imaging performed for abdominal related clinical suspicions, the initial 9 years was observed to have a 51.4% reduction in the number of primary abdominal images (US/CT) performed. The latter 9 year patient population was also noted to have more individuals whose induction dates were listed, therefor included in the analysis; 32.1% larger in size than the first 9 years group. First 9 years: Each CT abdomen was within normal limits. One abdominal ultrasound was concerning for acute acalculous cholecystitis within this group, in which further investigation was warranted i.e ERCP Latter 9 years: One CT abdomen was of concern depicting distension of the gallbladder without evidence of cholelithiasis and also visible pericholecystic fluid likely secondary to ascites. Two abdominal ultrasounds were concerning for sludge however without signs of acute cholecystitis nor acute acalculous cholecystitis. These three results were not clinically significant to warrant further investigation Conclusion: Evidence based guidelines that correlates clinical presentation with the appropriate timing and indication of diagnostic imaging with AML patients is currently not well known in literature. Due to the lack of guidance, the decision to obtain diagnostic imaging may differ from providers leading to inconsistent care and multiple diagnostic imaging that may not be clinically significant. In this observational retrospective study at this institution, what was discovered was the increased overutilization of abdominal medical diagnostic imaging (US/CT) over the years that grossly did not result with findings that required further investigation or adjustment in AML therapeutic management. Disclosures No relevant conflicts of interest to declare.