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Hemophagocytic lymph histiocytosis (HLH) is not an independent disease but is instead a clinical syndrome that occurs in many underlying conditions involving all age groups. HLH is the consequence of a severe, uncontrolled hyperinflammatory reaction that in most cases is triggered by an infectious agent. Acquired HLH is much more common than primary HLH syndrome but primary is more fatal, and it does have the worst prognosis with no definitive treatment available to date. This review article mentioned all the latest advancements regarding etiologies, pathogenesis, treatment, and outcomes in critically ill patients who got diagnosed with HLH syndrome in last 15 years.

Objective: To assess the severity of ulcerative colitis on first colonoscopic examination. Study Design: Prospective cross-sectional (correlational) study design. Place and Duration of Study: Study was conducted in Gastroenterology Outpatient Department of Pak Emirates Military Hospital, Rawalpindi, from Nov 2017 to Oct 2018. Methodology: An aggregate of 200 patients within the age range of 12-70 years, were included in the studythrough non-probability consecutive sampling. The data was collected by the self-administered questionnaireincluding age, gender, stool frequency, P/R bleed, systemic features of ulcerative colitis & colonoscopic findings.Effectiveness of the procedures was noted on a pre-designed performa and the endoscopic assessment was based upon mayo score severity of colitis graded from Normal (0) to Severe (3). Data was analyzed by using SPSS-19. Results: The mean age of the participants was reported 38 ± 2.1 years. Out of 200 participants 104 (52%) weremale, diarrhea with PR bleed was positive in 180 (90%) & anemia in 154 (77%). Colonoscopic findings showedthat 72 (36%) were with Left sided colitis (Montreal Class E2) & 82 (41%) with proctitis (Montreal class E1). Severe disease (Mayo endoscopic Score 3) was positive in 118 (59%) patients. Conclusion: Assessment of severity of UC is important as it determines the long term management & alsovaluable for risk stratification to predict the prognosis. Our findings feature the requirement for system levelenhancements to encourage the proper delivery of colonoscopy services dependent on individual risk. Keywords: , , , .

Objective: To look for frequency and associated socio-demographic factors of newly diagnosed patients of heap-tocellular carcinoma (HCC) among patients treated adequately for hepatitis C infection. Study Design: Correlational study. Place and Duration of Study: Gastroenterology Department, Pak Emirates Military Hospital Rawalpindi, from Nov 2017 to Oct 2018. Methodology: This analysis was performed on 170 patients treated effectively for hepatitis C with standard anti-viral therapy at our hospital. They were followed up for two years after the sustained viral response has been achieved. Ultrasonography was done in all cases and contrast enhanced computerized tomography scan done on patients who were positive on ultrasound. Factors like age, gender, genotype of heaptocellular carcinoma, presence of cirrhosis and model for end-stage liver disease (MELD) score were related with presence of heaptocellular carcinoma among the target population. Results: Out of 170 patients included in final analysis 121 were male, 49 were female. About 53 patients were diagnosed as suffering from heaptocellular carcinoma while 117 were negative for that. Thirty six patients had cirrhosis while 134 non cirrhotic. After applying the binary logistic regression genotypes other than 3, high model for end-stage liver disease score & presence of cirrhosis had a strong relationship with presence of heaptocellular carcinoma among the patients treated for hepatitis C virus. Conclusion: Physicians and patients cannot ignore the possibility of a malignant outcome even after successful treatment of hepatitis C. Local protocols should be set for screening especially the high risk cases even after treatment of hepatitis C virus with special attention to patients with genotype other than 3, cirrhosis & high model for end-stage liver disease score on follow up visits.

Importance On the basis of observational studies, the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Data from randomized clinical trials are lacking. Objective To examine whether the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Design, Setting, and Participants Using Veterans Affairs and Medicare claims data, this study examined hip and pelvic fracture hospitalizations in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial participants randomized to first-step therapy with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an angiotensin-converting enzyme inhibitor (lisinopril). Recruitment was from February 1994 to January 1998; in-trial follow-up ended in March 2002. The mean follow-up was 4.9 years. Posttrial follow-up was conducted through the end of 2006, using passive surveillance via national databases. For this secondary analysis, which used an intention-to-treat approach, data were analyzed from February 1, 1994, through December 31, 2006. Main Outcomes and Measures Hip and pelvic fracture hospitalizations. Results A total of 22 180 participants (mean [SD] age, 70.4 [6.7] years; 43.0% female; and 49.9% white non-Hispanic, 31.2% African American, and 19.1% other ethnic groups) were followed for up to 8 years (mean [SD], 4.9 [1.5] years) during masked therapy. After trial completion, 16 622 participants for whom claims data were available were followed for up to 5 additional years (mean [SD] total follow-up, 7.8 [3.1] years). During the trial, 338 fractures occurred. Participants randomized to receive chlorthalidone vs amlodipine or lisinopril had a lower risk of fracture on adjusted analyses (hazards ratio [HR], 0.79; 95% CI, 0.63-0.98;P = .04). Risk of fracture was significantly lower in participants randomized to receive chlorthalidone vs lisinopril (HR, 0.75; 95% CI, 0.58-0.98;P = .04) but not significantly different compared with those randomized to receive amlodipine (HR, 0.82; 95% CI, 0.63-1.08;P = .17). During the entire trial and posttrial period of follow-up, the cumulative incidence of fractures was nonsignificantly lower in participants randomized to receive chlorthalidone vs lisinopril or amlodipine (HR, 0.87; 95% CI, 0.74-1.03;P = .10) and vs each medication separately. In sensitivity analyses, when 1 year after randomization was used as the baseline (to allow for the effects of medications on bone to take effect), similar results were obtained for in-trial and in-trial plus posttrial follow-up. Conclusions and Relevance These findings from a large randomized clinical trial provide evidence of a beneficial effect of thiazide-type diuretic therapy in reducing hip and pelvic fracture risk compared with treatment with other antihypertensive medications. Trial Registration clinicaltrials.gov Identifier:NCT00000542

Background HIV infection in pregnant females confers a higher risk of morbidity and obstetric complications. Widespread use of anti-retroviral therapy (ART) has dramatically decreased vertical HIV transmission. US HIV-infected pregnant females continue to be at higher risk for obstetric complications compared with nonHIV infected females. This study will be conducted with the objective to estimate the current US morbidity and mortality in HIV-infected pregnant females as well as incidence of obstetric complications in this patient population. Methods The National Inpatient Sample (NIS) was utilized to identify hospitalizations associated with pregnancy from 2002 to 2014. The aggregation of hospitalizations was stratified into 2 groups based on HIV status to determine whether there were differences in demographic factors, complications, and mortality. All analyses accounted for the NIS sampling design. Results There were 39,404,956 pregnancy-related hospitalizations identified; of which, 51,762 were also associated with a positive HIV status. There were differences in complications for those with and without HIV, which included eclampsia (1.27% vs. 0.45%; P < 0.001), preterm labor (11.81% vs. 6.41%; P < 0.001), gestational diabetes (0.92% vs. 0.38%; P < 0.001), group B strep (0.03% vs. Conclusion As ART are readily available, we expected better outcomes for our HIV-positive pregnant females. Our results are concerning that there is such an increase rate of mortality and health disparity in HIV-positive pregnant females. As this is a retrospective study, there are limitation and further studies need to be conducted. Disclosures All authors: No reported disclosures.

Background As the pipeline for antibiotics is decreasing and antibiotic resistance is increasing, it is critically important to be stewards of antibiotics. ASP has become a mandated program as of January of 2017 by Joint Commission and condition of participation for CMS on reimbursement. A pilot program of C. difficile treatment in the academic medical center proved to be quite useful to adapt to a larger healthcare system. Methods A dedicated Infectious Disease physician and three Antibiotics stewardship pharmacists (ASP) were hired to run this program. Goals of the program was to decrease broad-spectrum antibiotics use, and reduce Clostridium difficile readmission (CDR) for the healthcare system. Performance of CDR for each inpatient was accomplished with ASP making recommendations for treatment. Queries were built into the ASP software and alerts were generated in the electronic medical record (EMR). CDR was targeted daily for ASP pharmacists/ID physician. Comparison of fiscal year 2017 (control group) with 2018 (intervention group) was performed. Results CDR was reduced (control group 17.53% vs. intervention group 14.12%), respectively, for our healthcare system (P > 0.05). However, overall cost savings for the healthcare system was $1.3 million was realized. In the academic medical center specifically, with over 400 beds there was a significant reduction in CDR (control group 21% to intervention group 10.5% (P < 0.05). Cost savings estimated from CDR were $610,923. Finally, length of stay was reduced by 1 day for inpatients with C. difficile admission in the academic medical center. Conclusion ASP not only has immediate impact on patient care and safety but also can play a large role in treating the appropriate disease state and reduces unnecessary readmission to the acute care hospitals in our healthcare system. Disclosures All authors: No reported disclosures.

A 37-year-old man presented with worsening headache, vomiting, and right-sided weakness over the last few weeks. A head computed tomography showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple enhancing mass lesions. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. An absolute CD4 count was 22 cells/μL. Other laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, luteinizing hormone, and testosterone. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge.