18F-Sodium fluoride positron emission tomography, aortic disease activity and ischaemic stroke risk

Background

Arterial 18F-sodium fluoride (18F-NaF) activity on positron emission tomography (PET) is a marker of active microcalcification and atherosclerosis. Coronary 18F-NaF activity (CMA) predicts coronary artery disease progression and subsequent myocardial infarction.

Objective

To investigate whether aortic 18F-NaF activity (AMA) predicts thoracic aortic atherosclerotic disease progression and subsequent ischaemic stroke or myocardial infarction in patients with established cardiovascular disease.

Methods

In a post-hoc observational cohort study, we evaluated AMA and CMA in patients with stable coronary artery disease (n=239) or aortic stenosis (n=158) who had underwent thoracic 18F-NaF PET and computed tomography (CT). We assessed the associations between AMA or CMA and progression of calcified atherosclerotic plaque in both thoracic aortic and coronary territories on follow up CT, as well as subsequent ischaemic stroke or myocardial infarction.

Results

In 141 and 231 patients with repeat aortic and coronary CT imaging respectively at 12.7±2.7 months, AMA correlated with log progression of thoracic aortic calcium scores (r=0.21, p=0.011), volume (r=0.29, p<0.01) and mass (r=0.29, P<0.01) as well as log coronary calcium score progression (r=0.21, p=0.03). CMA correlated with log coronary (r=0.42, p<0.01), but not log aortic (p>0.80) calcium score progression. In 397 patients, 16 had an ischaemic stroke and 25 had a myocardial infarction after 4.7±1.6 years. After adjusting for clinical risk factors, CMA and calcium scoring, AMA was associated with stroke (hazard ratio, 1.71 [95% confidence interval 1.00–2.90], p=0.048]). AMA was superior to clinical risk and calcium scores in identifying patients with stroke (c-statistic 0.76 versus 0.58 versus 0.63 respectively, p<0.05). Survival analysis demonstrated that AMA was associated with ischaemic stroke (p<0.001) but not myocardial infarction (p=0.45), whereas CMA was associated with myocardial infarction (p<0.001) but not stroke (p=0.39).

Conclusions

In patients with established cardiovascular disease, AMA is associated with progression of aortic atherosclerosis and future ischaemic stroke. Arterial 18F-NaF identifies localised areas of atherosclerotic disease activity that relate to regional atherothrombotic events.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation AMA, disease progression and outcomesVariables associated with stroke

905 Inferior Mesenteric Artery Branch Aneurysm Causing Ischemic Colitis – A Sequela of Anabolic Steroid Use

An inferior mesenteric artery (IMA) aneurysm comprises less than 1% of all reported visceral artery aneurysms. A 34-year-old bodybuilder with a history of anabolic steroid (AS) use of unknown duration, dose and frequency initially presented to the hospital with recurrent bouts of acute onset abdominal pain and alternating episodes of watery-mucous diarrhoea and constipation. Patient’s medical history was otherwise unremarkable with no stigmata of any connective tissue disorders.

A diagnosis of ischemic colitis secondary to a distal IMA branch aneurysm measuring 6mm x 5mm x 10mm on CT was made three years after first presentation. Flexible sigmoidoscopy confirmed mucosal changes consistent with sigmoid ischemic colitis.

A robotic anterior resection was performed due to two failed attempts at coiling the aneurysm. The histology was consistent with a secondary fibromuscular dysplasia in the IMA and its branches. There was a resolution of symptoms and return to normal stool and bowel function post-operatively.

The commonest cause of an IMA aneurysm is the “jet disorder” phenomenon caused by incomplete atherosclerotic occlusion of the superior mesenteric (SMA) and celiac arteries (CA). While the link between AS use and dyslipidaemia is established, the patient’s lipid profile was normal. We believe this case lends valuable insight into atypical causes of ischemic colitis and adds to the literature on AS use and vascular pathology.

Functional Outcome of Open Latarjet Procedure in Non-Athletic Middle-Aged Patients

Introduction:

The movement and steadiness of the shoulder joint is due to both the dynamic and static stabilisers. Recurrent anterior shoulder instability is common due to the Bankart lesion or the Hill Sachs lesion. The bone loss and soft tissue failure due to these lesions causing instability is well compensated by Latarjet procedure which acts by triple blocking effect of the bone graft, the sling effect of the conjoint tendon of subscapularis and the ligament of the coracoacromial ligament stump.

Materials and methods:

Middle-aged patients with recurrent anterior shoulder dislocation and a mid-range instability on clinical assessment with an isolated glenoid bone loss of 20% or Bankart lesion with engaging Hill Sachs lesion were selected for the study. The surgical procedure included a subscapularis split to expose the glenoid. The coracoid graft harvested was prefixed with Kirschner wires and placed flush over the glenoid ensuring no medial or lateral overhang and fixed with 4.0mm cancellous screws with the washer. The functional outcome was measured with the ROWE score and ASES score and the movements were evaluated.

Results:

A total of 24 patients fulfilled the inclusion criteria. Post-operatively at final follow-up, the mean ROWE score was 97.08 ±8.45 and the mean ASES score was 94.4±9.10. One patient had screw breakage as a complication and another had restriction of movement which was managed with physiotherapy.

Conclusion:

Open Latarjet is an effective procedure for recurrent anterior shoulder instability in non-athletic middle-aged patients as a excellent functional outcome was achieved with this technique. We therefore recommend open Latarjet as an alternative to arthroscopic treatment in developing countries where patient affordability and the availability of the resources are the issues.

Assessment of the introduction of semi-digital consent into surgical practice

In this study, paper-based surgical consent is demonstrated to have significant errors of omission and legibility. These errors were improved by the introduction of a procedure-specific, patient-bespoke, semi-digital consent form application. Patient-reported experience of their involvement in shared decision-making is described for paper-based consent and the implications of future digital consent are discussed.

701 Combined Endovascular and Percutaneous Treatment of Traumatic Pseudoaneurysm of Profunda Femoris Artery: A Case Report

Pseudoaneurysms of the profunda femoris artery are rare complications of femoral fractures, seen especially after orthopaedic interventions for the same.

We present a case of an 89-year-old Caucasian male with a left neck of femur fracture, repaired with a dynamic hip screw. He presented to us a month later with a painful swollen thigh and deep vein thrombosis. The patient underwent arterial duplex and CT angiogram scans and was found to have a pseudoaneurysm in his left profunda femoris artery, measuring 3x3x4.5cm. This was treated with balloon angioplasty and stenting. However, his stent surveillance duplex scan, a month later, showed that the pseudoaneurysm was largely thrombosed with a patent core that was being fed by a communicating vessel from the superficial femoral artery. A subsequent angiogram showed no obvious feeding vessel. The patent pseudoaneurysm was then treated by percutaneous injection of thrombin. Exclusion of the pseudoaneurysm was confirmed by a follow-up duplex scan.

It is essential to treat all feeding vessels of pseudoaneurysms in the presence of a rich collateral supply. Profunda femoris false aneurysms can thus be treated entirely by endovascular/percutaneous methods and so, potentially avoid open surgery.

Can We Avoid Axillary Lymph Node Dissection (ALND) in Patients with 1-2 Positive Sentinel/Low Axillary Lymph Nodes (SLN/LAS+) in the Indian Setting?

The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.

A Multicenter Study of the Clinical Utility of Nontargeted Systematic Transperineal Prostate Biopsies in Patients Undergoing Pre-Biopsy Multiparametric Magnetic Resonance Imaging

PURPOSE

The added value of nontargeted systematic prostate biopsies when performed alongside magnetic resonance imaging targeted biopsies in men referred with a suspicion of prostate cancer is unclear. We aimed to determine the clinical utility of transperineal nontargeted systematic prostate biopsies, when performed alongside targeted systematic prostate biopsies, using pre-biopsy multiparametric magnetic resonance imaging.

MATERIALS AND METHODS

Consecutive patients referred with a suspicion of prostate cancer (April 2017 to October 2019) underwent pre-biopsy multiparametric magnetic resonance imaging. A transperineal biopsy was advised if multiparametric magnetic resonance imaging PI-RADS® (v.2.0) score was 4 or 5, and score 3 required a prostate specific antigen density 0.12 ng/ml or greater. Primary threshold for clinically significant prostate cancer was defined as any Gleason 3+4 or greater. Multivariable logistic regression analysis identified pre-biopsy predictors of clinically significant prostate cancer in nontargeted systematic prostate biopsies, regardless of targeted pathology (p <0.05, R, version 3.5.1).

RESULTS

A total of 1,719 men underwent a pre-biopsy multiparametric magnetic resonance imaging, with 679 (39.5%) proceeding to combined targeted systematic prostate biopsies and nontargeted systematic prostate biopsies. In these men clinically significant prostate cancer was detected in 333 (49%) and 139 (20.5%) with targeted systematic prostate biopsies and nontargeted systematic prostate biopsies, respectively. In those men with clinically significant prostate cancer in targeted systematic prostate biopsies, clinically significant prostate cancer was also present in nontargeted systematic prostate biopsies in 117 (17.2%); Gleason 3+3 was present in 50 (7.4%). In 287 men without any cancer in the targeted systematic prostate biopsies, 13 (1.9%) had clinically significant prostate cancer in nontargeted systematic prostate biopsies. In addition 18/679 (2.7%) had Gleason 3+3 disease and no Gleason greater than 4+3 was detected. Predictors associated with clinically significant prostate cancer in nontargeted systematic prostate biopsies were prostate specific antigen 5 ng/ml or greater (OR 2.05, 95% CI 1.13-3.73, p=0.02), PI-RADS score 5 (OR 2.26, 95% CI 1.51-3.38, p <0.001) and prostate volume less than 50 cc (OR 2.47, 95% CI 1.57-3.87, p <0.001).

CONCLUSIONS

Detection of clinically significant prostate cancer in exclusively nontargeted transperineal systematic biopsies in a pre-biopsy multiparametric magnetic resonance imaging pathway was low (1.9%).

ACE2/ACE imbalance and impaired vasoreparative functions of stem/progenitor cells in aging

Aging increases risk for ischemic vascular diseases. Bone marrow–derived hematopoietic stem/progenitor cells (HSPCs) are known to stimulate vascular regeneration. Activation of either the Mas receptor (MasR) by angiotensin-(1-7) (Ang-(1-7)) or angiotensin-converting enzyme-2 (ACE2) stimulates vasoreparative functions in HSPCs. This study tested if aging is associated with decreased ACE2 expression in HSPCs and if Ang-(1-7) restores vasoreparative functions. Flow cytometric enumeration of Lin⁻CD45^lowCD34⁺ cells was carried out in peripheral blood of male or female individuals (22–83 years of age). Activity of ACE2 or the classical angiotensin-converting enzyme (ACE) was determined in lysates of HSPCs. Lin⁻Sca-1⁺cKit⁺ (LSK) cells were isolated from young (3–5 months) or old (20–22 months) mice, and migration and proliferation were evaluated. Old mice were treated with Ang-(1-7), and mobilization of HSPCs was determined following ischemia induced by femoral ligation. A laser Doppler blood flow meter was used to determine blood flow. Aging was associated with decreased number (Spearman r = − 0.598, P < 0.0001, n = 56), decreased ACE2 (r = − 0.677, P < 0.0004), and increased ACE activity (r = 0.872, P < 0.0001) (n = 23) in HSPCs. Migration or proliferation of LSK cells in basal or in response to stromal-derived factor-1α in old cells is attenuated compared to young, and these dysfunctions were reversed by Ang-(1-7). Ischemia increased the number of circulating LSK cells in young mice, and blood flow to ischemic areas was recovered. These responses were impaired in old mice but were restored by treatment with Ang-(1-7). These results suggest that activation of ACE2 or MasR would be a promising approach for enhancing ischemic vascular repair in aging.

Estimation of height and width of bone in anterior hard palate as a donor site for autogenous bone graft using IOPA by long cone paralleling technique

Objective

The purpose of this study was to determine the amount of bone available for harvesting from the anterior palate region using IOPA (Intra Oral Peri Apical) radiographs.

Materials and Methods

A total of 80 patients visiting the outpatient Department of Periodontics were selected. Two groups of male and female consisting 40 patients each were made. They were further subdivided into two groups based on age, 18-30 and 31-60 years of age, each with twenty patients. The patients were subjected to radiographic examination consisting of IOPA radiographs. All IOPA radiographs were taken using long cone paralleling technique. Availability of bone for harvesting, above the apices of teeth was calculated.

Results

The bone available in the incisor region was approximately 6.5 to 6.9 mm in height and 7.4 to 8 mm in width, in canine region 6.35 to 6.65 mm in height and 7.6 to 8.1 mm width, and in the premolar region 3.65 to 3.75 mm in height and width. When the bone height and width were compared gender and age wise for CI (central incisors), LI (lateral incisors), canine and premolars, using Student's t- test the results were not statistically significant.

Conclusion

For the purpose of harvesting autogenous bone, from the region of incisor and canine approximately 6.35 to 6.9 mm height and 7.4 to 8.1 mm width of bone may be harvested maintaining a safe distance from the apices of the teeth and the nasal floor. The premolar region does appear to yield sufficient bone at safe distances from the maxillary sinus and the apices of the premolars.

Patient characteristics and in-hospital outcomes of Takotsubo Cardiomyopathy in pregnancy: a retrospective analysis

Introduction

Takotsubo Cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction and predominantly affects post-menopausal women. However, it is rarely identified as a cause of acute heart failure in pregnancy.

Objective

We aimed to determine patient characteristics and in-hospital outcomes of TCM occurring in pregnancy.

Methods

We retrospectively analyzed the United States - National Inpatient Sample (NIS) Database from 2010–2014 to assess TCM in pregnant women ≥18 years using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. We compared patient demographics, co-morbidities and in-hospital outcomes between pregnant and non-pregnant women with TCM aged 18–49 years. Patients with a diagnosis of peripartum cardiomyopathy were excluded. Chi-square test and Student-t test or Mann- Whitney U test were used for categorical and continuous variables with normal and skewed distribution, respectively.

Results

TCM occurred at a younger age in pregnant women compared to non-pregnant women (Age [Mean ±SD]: 31.2±7.2 years vs. 41.8±7.1 years; p&lt;0.001). Rates of TCM were higher during pregnancy in African American (19% vs. 11.5%; p=0.008), Hispanic (27.3% vs. 9.6%; p&lt;0.001) and Asian women (11.3% vs. 2.6%; p&lt;0.001) compared to non-pregnant women of similar race. However, among Caucasian women rates of TCM were higher in non-pregnant women (42.4% vs. 72.7%; p&lt;0.001). There were no in-hospital deaths among pregnant women with TCM (0% vs. 5.2%; p=0.005), however they had higher rates of cardiogenic shock (13.8% vs. 5.8; p&lt;0.001) and respiratory failure requiring mechanical ventilation (51.7% vs. 20.9%; p&lt;0.001). The average length of hospitalization was also longer among pregnant women with TCM (Days [Mean±SD]: 5.8±4 vs. 5.5±7.5; p&lt;0.001). Pregnant women had lower rates of diagnostic angiography (24.1% vs. 55.6%; p&lt;0.001). Pregnant women with TCM had higher rates of ventricular fibrillation (6.9% vs. 2.9%; p=0.02), but had no atrial fibrillation (0% vs. 2.6%; p=0.05), atrial flutter (0% vs. 0.4%; p=0.43), paroxysmal supraventricular tachycardia (0% vs. 0.5%; p=0.4) and ventricular tachycardia (0% vs. 4.8%; p=0.07). Pregnant women with TCM had lower rates of psychiatric and certain medical co-morbidities: anxiety (6.9% vs. 20.4%; p&lt;0.001), depression (0% vs. 2.6%; p=0.05), bipolar disorder (0% vs. 0.8%; p=0.3), hypertension (27.6% vs. 40.3%; p=0.002), hyperlipidemia (3.4% vs. 25.7%; p&lt;0.001) and smoking (6.9% vs. 40.2%; p&lt;0.001). The rates of diabetes (13.8% vs. 15.9%; p=0.5) and obesity (10.3% vs. 8.2%; p=0.37) were similar between the two groups.

Conclusion

There was no in-hospital mortality observed in pregnant women who developed TCM, however, they had increased rates of cardiogenic shock, mechanical ventilation, ventricular fibrillation and had longer hospitalizations.

Funding Acknowledgement

Type of funding source: None

Vaccine-preventable diseases in hospitalized patients with heart failure: a nationwide cohort analysis

Introduction

Infection related hospitalizations are common among patients with heart failure (HF), including those that could be prevented with appropriate vaccinations.

Objective

We aimed to determine the risk of vaccine preventable diseases (VPDs) in patients with HF.

Methods

We performed a population based retrospective cohort study using the United States- National Inpatient Sample (NIS) Database from 2010 to 2014. We identified patients who were admitted to the hospital with vaccine preventable diseases, namely influenza, varicella zoster infection (VZV), pneumococcal infection, meningococcal infection, diphtheria, pertussis, tetanus, hepatitis A (Hep A) and hepatitis B (Hep B) using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. In this cohort, we then identified patients with HF. Descriptive statistics were used to estimate the frequencies of various VPDs in patients with heart failure. A multivariate regression model adjusting for age, gender, race, immunosuppression (Diabetes, HIV, Organ transplantation, Malignancy) was employed to determine the risk of VPDs in patients with HF.

Results

Among a total of 11, 64,528 patients admitted with VPDs, HF was present in 1, 01,915 (8.8%).The most common VPD in patients with HF was VZV (30.7%), followed by influenza (28.2%), pneumococcal infection (20.9%) and Hep B (18.5%). Other VPDs were less common: Hep A (1.8%), diphtheria (0.4%), pertussis (0.2%), tetanus (10 patients) and meningococcal infection (0.1%). On multivariate analysis, patients with HF had increased risk of hospitalization due to influenza (aOR=1.20, 95% CI: 1.18–1.21; p&lt;0.001) and pneumococcal infection (aOR=1.31, 95% CI: 1.29–1.33; p&lt;0.001), but were at a lower risk of hospitalization due to VZV (aOR=0.81, 95% CI: 0.8–0.83; p&lt;0.001), Hep B (aOR=0.78, 95% CI: 0.77- 0.8; p&lt;0.001), Hep A (aOR=0.71, 95% CI: 0.67–0.74; p&lt;0.001), Meningococcal infection (aOR=0.64, 95% CI: 0.52–0.78; p&lt;0.001), diphtheria (aOR=0.79, 95% CI: 0.71–0.88; p&lt;0.001) and tetanus (aOR=0.35, 95% CI: 0.19–0.65; p=0.001). No statistically significant association of HF was observed with pertussis (p=0.167).

Conclusion

In our study, patients with HF had a higher risk of hospital admissions secondary to influenza and pneumococcal infections and a lower risk of VZV, Hep B, Hep A, meningococcal infection, diphtheria, and tetanus related admissions when compared with non-HF patients.

Funding Acknowledgement

Type of funding source: None