TP9.2.3Laparoscopic Cholecystectomy with Intraoperative Cholangiogram and Antegrade Biliary Stenting in Acute Gall Stone Pancreatitis: A Cohort Study

Aims To demonstrate feasibility and efficacy of laparoscopic cholecystectomy (LC), intraoperative (IOC) and antegrade biliary stenting (ABS) as compared to selective pre-operative biliary investigation and intervention in acute gallstone pancreatitis (AGP). Methods A cohort study was performed comparing patients who had IOC+/-ABS during LC versus those who had only LC in the treatment of AGP. 74 consecutive AGP patients were included in this study from January 2016 to October 2018. All patients were included in a prospective database with follow-up for one year. Results 47 (64.5%) patients underwent IOC during LC (7 required ABS insertion), with a mean age 51 years (SEM: 2.7), 72.3% were female. The median admission bilirubin was 24 (IQR:14-54). The average number of ERCP and MRCP per patient was 0.30 and 0.15 respectively. 27 (36.5%) patients underwent LC with selective pre-operative biliary investigation with a mean age 48 years (SEM: 2.9), 66.7% were female. The median admission bilirubin was 27 (IQR:14-48). The average number of ERCP and MRCP per patient was 0.41 and 0.52 respectively. Discussion In our pilot study comparing LC with IOC versus LC with selective pre-operative biliary investigation we demonstrate that, there is marked reduction in biliary investigations required in IOC group. Length of hospital admissions and rate of post-operative complications were comparable. An analytic study with a larger cohort may demonstrate further seniority of IOC.

Clinical frailty as a key characteristic of the patient population of the NHS Nightingale North West COVID-19 temporary emergency field hospital: cohort study April to June 2020

Objectives COVID-19 temporary emergency ‘field’ hospitals have been established in the UK to support the surge capacity of the National Health Service while protecting the community from onward infection. We described the population of one such hospital and investigated the impact of frailty on clinical outcomes. Design Cohort study. Setting NHS Nightingale Hospital North West, April–June 2020. Participants All in-patients with COVID-19. Main Outcome Measures Mortality and duration of admission. Methods We analysed factors associated with mortality using logistic regression and admission duration using Cox's regression, and described trends in frailty prevalence over time using linear regression. Results A total of 104 COVID-19 patients were admitted, 74% with moderate-to-severe frailty (clinical frailty score, CFS > 5). A total of 84 were discharged, 14 transferred to other hospitals, and six died on site. High C-reactive protein (CRP) > 50 mg/dL predicted 30-day mortality (adjusted odds ratio 11.9, 95%CI 3.2–51.5, p < 0.001). Patients with CFS > 5 had a 10-day median admission, versus 7-day for CFS ≤ 5 and half the likelihood of discharge on a given day (adjusted hazard ratio 0.51, 95%CI 0.29–0.92, p = 0.024). CRP > 50 mg/dL and hospital-associated COVID-19 also predicted admission duration. As more frail patients had a lower rate of discharge, prevalence of CFS > 5 increased from 64% initially to 90% in the final week (non-zero slope p < 0.001). Conclusions: The NNW population was characterized by high levels of frailty, which increased over the course of the hospital's operation, with subsequent operational implications. Identifying and responding to the needs of this population, and acknowledging the risks of this unusual clinical context, helped the hospital to keep patients safe.

Comparison of effectiveness and outcomes among different thrombectomy techniques in acute basilar artery occlusion: a dual-center experience

OBJECTIVE Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever–assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort. METHODS A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis. RESULTS Eighty-three patients (median age 67 years [IQR 58–76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10–21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5–363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0–2) was not significantly different among the three techniques. Poor outcome (mRS score 3–6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97–0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18–2.39; p = 0.005). CONCLUSIONS The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

Predictors for affected stroke territory and outcome of acute stroke treatments are different for posterior versus anterior circulation stroke

Distinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790–0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935–0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111–3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806–0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory.

Association of endothelial activation assessed through endothelin-I precursor peptide measurement with mortality in COVID-19 patients: an observational analysis

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) has been linked to thrombotic complications and endothelial dysfunction. We assessed the prognostic implications of endothelial activation through measurement of endothelin-I precursor peptide (proET-1), the stable precursor protein of Endothelin-1, in a well-defined cohort of patients hospitalized with COVID-19. Methods We measured proET-1 in 74 consecutively admitted adult patients with confirmed COVID-19 and compared its prognostic accuracy to that of patients with community-acquired pneumonia (n = 876) and viral bronchitis (n = 371) from a previous study by means of logistic regression analysis. The primary endpoint was all-cause 30-day mortality. Results Overall, median admission proET-1 levels were lower in COVID-19 patients compared to those with pneumonia and exacerbated bronchitis, respectively (57.0 pmol/l vs. 113.0 pmol/l vs. 96.0 pmol/l, p < 0.01). Although COVID-19 non-survivors had 1.5-fold higher admission proET-1 levels compared to survivors (81.8 pmol/l [IQR: 76 to 118] vs. 53.6 [IQR: 37 to 69]), no significant association of proET-1 levels and mortality was found in a regression model adjusted for age, gender, creatinine level, diastolic blood pressure as well as cancer and coronary artery disease (adjusted OR 0.1, 95% CI 0.0009 to 14.7). In patients with pneumonia (adjusted OR 25.4, 95% CI 5.1 to 127.4) and exacerbated bronchitis (adjusted OR 120.1, 95% CI 1.9 to 7499) we found significant associations of proET-1 and mortality. Conclusions Compared to other types of pulmonary infection, COVID-19 shows only a mild activation of the endothelium as assessed through measurement of proET-1. Therefore, the high mortality associated with COVID-19 may not be attributed to endothelial dysfunction by the surrogate marker proET-1.

Differentiation between myopericarditis and acute myocardial infarction on presentation in the emergency department using the admission C-reactive protein to troponin ratio

Background The treatment of myopericarditis is different than that of acute myocardial infarction (AMI). However, since their clinical presentation is frequently similar it may be difficult to distinguish between these entities despite a disparate underlying pathogenesis. Myopericarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We hypothesized that evaluation of the CRP/troponin ratio on presentation to the emergency department could improve the differentiation between these two related clinical entities whose therapy is different. Such differentiation should facilitate triage to appropriate and expeditious therapy. Methods We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large single center registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed on discharge as myopericarditis. CRP and troponin were sampled on admission in all patients and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of myopericarditis against all AMI, STEMI, and NSTEMI patients. Results Median admission CRP/troponin ratios were 84, 65, and 436 mg×ml/liter×ng in STEMI, NSTEMI and myopericarditis groups, respectively (p<0.001) demonstrating good differentiating capability. The Receiver-operator-curve of admission CRP/troponin ratio for diagnosis of myopericarditis against all AMI, STEMI, and NSTEMI patients yielded an area-under-the curve of 0.74, 0.73, and 0.765, respectively. CRP/troponin ratio>500 resulted in specificity exceeding 85%, and for a ratio>1000, specificity>92%. Conclusion The CRP/troponin ratio can serve as an effective tool to differentiate between myopericarditis and AMI. In the appropriate clinical context, the CRP/troponin ratio may preclude further evaluation.

The c- reactive protein to troponin ratio enhances the differentiation of perimyocarditis from acute myocardial infarction

Funding Acknowledgements Type of funding sources: None. Differentiating perimyocarditis from acute myocardial infarction (AMI) is frequently difficult . Perimyocarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We surmised that the CRP/troponin ratio on presentation could improve the differentiation between these two clinical entities. We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large hospital registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed as perimyocarditis. CRP and troponin were sampled on admission and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of perimyocarditis against STEMI with or without NSTEMI. Median admission CRP/troponin ratios were 84, 65, and 436 mg × ml/liter × ng in STEMI, NSTEMI and perimyocarditis groups, respectively (p &lt; 0.001) demonstrating good differentiating capability. The ROC of admission CRP/troponin ratio for diagnosis of perimyocarditis against STEMI with or without NSTEMI yielded a similar AUC of 0.74 and 0.73, respectively. CRP/troponin ratio &gt; 500 resulted in specificity exceeding 85%. The CRP/troponin ratio is an effective tool that enhances the differentiation between perimyocarditis and AMI.

Activation of vasopressin system during COVID-19 is associated with adverse clinical outcomes: an observational study

Background Activation of the vasopressin system plays a key role for the maintenance of osmotic, cardiovascular and stress hormone homeostasis during disease. We investigated levels of copeptin, the C-terminal segment of the vasopressin prohormone, that mirrors the production rate of vasopressin in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods We measured levels of copeptin on admission and after 3/4, 5/6 and 7/8 days in 74 consecutive hospitalized adult COVID-19 patients and compared its prognostic accuracy to that of patients with community-acquired pneumonia (n=876) and acute or chronic bronchitis (n=371) from a previous study by means of logistic regression analysis. The primary endpoint was all-cause 30-day mortality. Results Median admission copeptin levels in COVID-19 patients were almost 4-fold higher in non-survivors compared to survivors (49.4 pmol/L (IQR 24.9-68.9 pmol/L) vs. 13.5 pmol/L (IQR 7.0-26.7 pmol/L) resulting in an age and gender-adjusted odds ratio of 7.0 (95%CI 1.2 to 40.3), p&lt;0.03 for mortality. Higher copeptin levels in non-survivors persisted during the short-term follow-up. Compared to the control group patients with acute/chronic bronchitis and pneumonia, COVID-19 patients did not have higher admission copeptin levels. Conclusions A pronounced activation of the vasopressin system in COVID-19 patients is associated with an adverse clinical course in COVID-19 patients. This finding, however, is not unique to COVID-19 but similar to other types of respiratory infections. .

Characteristics and outcomes of patients (pts) who developed immune-related adverse events (irAEs) with an initial presentation in the emergency department (ED).

201 Background: Management of irAEs due to immune checkpoint inhibitors (ICIs) requires a high degree of suspicion, and management of severe irAEs require timely initiation of corticosteroids (CS). This can be challenging in the ED, where providers may not be aware of an individual pt’s cancer treatment or its toxicities. Methods: We performed a retrospective single-center chart review for pts treated with ICIs in 2018 and 2019 who subsequently presented to ED. New irAEs with first presentation in ED were analyzed and pt outcomes were recorded. Descriptive statistics compared this population to irAEs identified in outpatient setting, as well as rates of ED utilization in pts on doublet ICI (dICI). Results: Of 351 evaluable pts treated with an ICI, 129 (37%) had at least one presentation to ED. Seventeen pts had a first presentation of a new irAE. These pts had received a median 2 cycles of ICI prior to presentation (interquartile range [IQR] 1-3) Twelve of these pts presented with generalized fatigue or pain, twelve required admission, 4 were admitted to intensive care within 30 days, and two died. Toxicities included hypophysitis (5), arthritis (2), colitis (2), myocarditis (2), neuritis (2), pneumonitis (2), adrenalitis (1), hepatitis (1). Median admission was 8.5 days (IQR 2-32), and median time to corticosteroids was 30.5 hours (range 4-269). Grade 3 or higher toxicity was more frequent in the ED pts compared to the total ICI pt population (70.5% vs. 32.2%). Pts on dICI (n = 41) had a higher rate of ED utilization (n = 23, 56.1%) and ED visits were more likely to be for first presentation of a new irAE (n = 7, 30.4% of dICI ED visits) compared to single-agent ICI regimens. Conclusions: Pts with irAEs that first present at the ED often have generalized symptoms, prolonged hospitalizations, and can have long delays to initiation of CS. Development of a protocolized approach for pts on ICI at the point of care in the ED may improve identification of irAEs, ‘door-to-steroid’ time, and patient outcomes.

Primary Multivessel Occlusions Treated With Mechanical Thrombectomy

Background and Purpose: Acute ischemic stroke caused by primary multivessel occlusions (pMVO) is a rare but devastating disease. Whether multi-target mechanical thrombectomy for pMVO is beneficial remains unknown. Methods: Multicenter retrospective review of patients treated with multi-target mechanical thrombectomy. The following pMVO sites were included: basilar artery, internal carotid artery, and middle cerebral artery (M1 and M2). Baseline characteristics were reported together with interventional technique, technical efficacy, and safety parameters. Clinical outcomes were evaluated applying the National Institutes of Health Stroke Scale and modified Rankin Scale. A systematic literature review was performed to summarize previous reports on pMVO mechanical thrombectomy. Results: Of 6081 patients screened, 21 patients met the inclusion criteria (0.35% [95% CI, 0.23%–0.53%]). In 70% (14/20) a cardioembolic cause was reported. A successful reperfusion of Thrombolysis in Cerebral Infarction scale score ≥2b was achieved in 95.2% (20/21) for the first and 76.1% (16/21) for the second target vessel. In those who survived the acute hospital stay (n=10/21), median admission National Institutes of Health Stroke Scale improved from 21 (interquartile range, 13–27) to 8 (interquartile range, 2–20) at discharge ( P =0.006). Mortality was 60% (12/20) at 90 days and only 20% (4/20) of patients reached modified Rankin Scale score ≤2. Acceptable outcomes were almost exclusively observed in pMVO patients presenting with at least one M2 occlusion. Conclusions: Multi-target mechanical thrombectomy for pMVOs is rarely performed; however, the procedure appears to be feasible and safe with high reperfusion rates for both occlusion sites. More than half of all treated patients deceased early and favorable outcomes may only be expected for pMVO patients including at least one M2 occlusion.