P5022Dual-energy CT was effective to evaluate of microvasculopathy in chronic thromboembolic pulmonary hypertension

Background

The existence of microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy CT (DECT) can produce a sensitive iodine distribution map as blood perfusion in lung fields to quantify lung perfusion, also can suggest the existence of microvasculopathy according to poor subpleural perfusion which was published previously.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 83 treatment-naïve CTEPH patients who underwent DECT from February 2014 to Jan 2019. Patients were divided according to poor subpleural perfusion: a microvasculopathy group (n=44) or a non-microvasculopathy group (n=39).

We assessed cardiopulmonary exercise test, right heart catheterization and DECT parameters as quantitative evaluation of pulmonary blood volume (PBV). PBV was calculated as the average of entire lung iodine density.

Results

PBV value in non-microvasculopathy group showed significant inverse correlation with pulmonary vascular resistance (PVR) (y = 14236 x-1.028 r=−0.530, p<0.01).

PBV, SvO2, and %DLCO/VA were significantly lower (22.0 vs. 26.4, p<0.01, 61.3 vs. 66.0, p<0.01, and 59.2 vs 75.9 p<0.01), and systolic pulmonary arterial pressure, PVR, VE/VCO2 slope, BNP were higher (69.3 vs 60.6 p=0.04, 834 vs 586 p<0.01, 45.5 vs. 37.8, p=0.02, and 440 vs 122 p=0.04) in microvasculopathy group, while the other parameters were similar between the two groups.

Multivariate analysis revealed that %DLCO/VA was the only predictor of microvasculopathy (OR,0.895 [95% CI, 0.835 - 0.960]; P<0.01).

Conclusion

Pulmonary blood flow of patients in non-micorvasculopathy group showed inverse correlation with PVR. DECT was effective to assess the microvasculopathy in CTEPH. In our experience, less than 60% of non-operable CTEPH patients have microvasculopathy.

P6468Balloon pulmonary angioplasty for patients with symptomatic chronic thromboembolic disease without pulmonary hypertension

Background

Chronic thromboembolic disease (CTED) is characterised by thromboembolic stenosis and obstruction of pulmonary arteries without pulmonary hypertension. The treatment approach for symptomatic patients with CTED is still controversial. It has been reported the efficacy of surgical endarterectomy for patients with CTED, however that of balloon pulmonary angioplasty (BPA) for non-operable CTED has not been well established.

Method

We started aggressive BPA protocol for non-operable CTED patients who suffered from symptom with NYHA class II, III, and IV or limitation of exercise in spite of mean pulmonary artery pressure (mPAP) <25 mmHg since February 2014. We evaluated subjective symptoms, hemodynamic parameters by right heart catheter, and exercise capacity by cardiopulmonary exercise test at baseline and after the last BPA session.

Results

Twenty-three patients with CTED (68.7±10.5 years-old, 7 male) had undergone BPA. In these, 7 patients had received pulmonary vasodilators previously. After 2.9±1.3 sessions of BPA, Further improvement was observed in hemodynamics such as mPAP (21.6±2.3 to 17.1±2.6 mmHg, p<0.01), pulmonary vascular resistance (278±80 to 198±63 dyne/s/cm–5, p<0.01), which were accompanied with improved peak VO2 (14.6±4.4 to 17.4±4.2 ml/min/kg, p<0.01), VE/VCO2 slope (39.6±14.6 to 30.2±6.0, p=0.01), and functional class (I/II/III/IV; 0/10/12/1 to 9/12/2/0, p<0.01) (Table). All patients were tolerable, and no severe complication regarding to BPA.

Table 1 Variables Baseline After BPA (3 month) P value NYHA class (I / II / III / IV) 0 / 10 / 12 / 1 9 / 12 / 2 / 0 <0.01 Mean PAP (mmHg) 21.6±2.3 17.1±2.6 <0.01 PVR (dyne/sec/cm–5) 278±80 198±63 <0.01 6 MWD (m) 354±93 382±96 0.09 Peak VO2 (ml/min/kg) 14.6±4.4 17.4±4.2 <0.01

Conclusion

BPA may have the potential to achieve further improvement of exercise capacity and symptoms in CTED patients with acceptable risk, therefore BPA should be considered as a treatment option for symptomatic patients with non-operable CTED.

P5504Comparison of in-hospital clinical outcomes of acute myocardial infarction between nonagenarians and octogenarians: a propensity-score matched analysis

Background

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Because the majority of study population in clinical researches focusing on the very elderly with AMI were octogenarians, clinical evidences regarding AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital clinical outcomes of AMI between octogenarians and nonagenarians.

Methods

We included consecutive 415 very elderly (≥80 years) patients with AMI, and divided into the nonagenarian group (n=38) and the octogenarian group (n=377). Clinical characteristics and in-hospital outcomes were compared between the 2 groups. Furthermore, we used propensity-score matching to find the matched octogenarian group (n=38).

Results

Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups The incidence of in-hospital death in the nonagenarian group (13.2%) was similar to that in the octogenarian group (14.6%) (P=0.811). The length of hospital stay was significantly shorter in the nonagenarian group (7.4±4.2 days) than that in the octogenarian group (15.4±19.4 days) (P<0.001). After using the propensity-score matching, the incidence of in-hospital death was less in the nonagenarian group (13.2%) than in the matched octogenarian group (21.1%) without reaching statistical significance (P=0.361). The length of hospitalization was significantly shorter in the nonagenarian group (7.4±4.2 days) than in the matched octogenarian group (17.8±37.0 days) (P=0.01).

Clinical outcomes Nonagenarian group (n=38) Octogenarian group (n=377) P value In-hospital death, n (%) 5 (13.2) 55 (14.6) 0.811 Length of hospital stay (days) 7.4±4.2 15.4±19.4 <0.001 Length of CCU stay (days) 3.3±2.5 4.7±5.1 0.109 LVEF (%) 48.2±9.2 50.8±13.7 0.152 Peak CPK (U/L) 1424.8±1580.8 1640.1±2394.4 0.912 CCU indicates Coronary care unit; LVEF, Left ventricular ejection fraction; CPK, Creatine kinase.

Flow-chart

Conclusions

The in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

Acknowledgement/Funding

None

C-arm cone-beam computed tomography-guided minimally invasive open excision of an osteoid osteoma undetectable on fluoroscopy: A case report

•

A robotic C-arm cone-beam computed tomography (CBCT) system provides a clear intraoperative visualization of the osteoid osteoma.

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C-arm CBCT allowed precise access to the tumor, accurate tumor resection, and minimal sacrifice of the normal bone in osteoid osteoma surgery.

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Repurpose use of the dilator, retractor, and wider trephine tips achieved more conservative results with a smaller skin incision.

Introduction

The small size of a nidus and the extensive sclerosis around it often make it difficult to identify tumors from the surrounding normal bone by fluoroscopy, and a large amount of bone resection might be required to secure complete removal during osteoid osteoma surgery. In this report, we present the first case of radiographically invisible osteoid osteoma that was successfully resected under a robotic C-arm cone-beam computed tomography (CBCT) imaging system.

Presentation of case

A 14-year-old boy presented with persistent pain around the left knee joint was diagnosed with osteoid osteoma of the left distal femur. Since the tumor was not detectable by intraoperative fluoroscopy, a CBCT system was used for guidance during an open tumor resection. For a less invasive surgery, we repurposed the dilator and retractor of the microendoscopic discectomy (MED) system and resected the tumor using the wider trephine tips for bone biopsy. At the final follow-up one year later, the function of the afflicted limb was normal with no complaint of any symptoms. Plain radiograph at the final follow-up showed new bone formation completely filling the bone defect, without local recurrence.

Discussion

CBCT allowed for clear intraoperative visualization of the osteoid osteoma, thereby promising a secure resection and less invasive osteoid osteoma treatment. Furthermore, the repurposed use of the dilator and retractor of the MED system as well as the wider trephine tips for bone biopsy made the procedure less invasive.

Conclusion

CBCT-guided minimally invasive open excision surgery could be a useful option for the management of radiographically invisible osteoid osteoma.

Determining Patient Satisfaction and Treatment Desires in Patients With Musculoskeletal Sarcoma of the Knee After Joint-preservation Surgery Using a Questionnaire Survey

BACKGROUND/AIM

For cases of musculoskeletal sarcoma of the knee presenting to our institute, we prioritize joint preservation whenever possible. To investigate patient satisfaction and desire for joint preservation, a questionnaire survey was performed.

PATIENTS AND METHODS

Surveys were mailed to 62 patients with musculoskeletal sarcoma of the knee. Responses concerning the patient and their families' satisfaction were evaluated on a 5-point Likert scale and their priorities for the surgery were noted as well.

RESULTS

The survey response rate was 67.7%. All but one person were above neutral for the 5-point Likert scale. Overall, the first priority was tumor removal followed by preservation of function.

CONCLUSION

Patients identified tumor removal as their first priority, which could increase satisfaction. Following that, better preservation of function could also increase patient satisfaction. Joint-preservation was consistent with these priorities.

Satisfaction After Joint-preservation Surgery in Patients With Musculoskeletal Knee Sarcoma Based on Various Scores

BACKGROUND/AIM

At our institute, we prioritize joint-preservation whenever possible in cases of musculoskeletal knee sarcoma. This study aimed to evaluate patient satisfaction after joint-preservation surgery using different scales.

PATIENTS AND METHODS

Surveys were mailed to 62 patients with musculoskeletal knee sarcoma. We analyzed the responders' data based on the Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), and three component scores (physical, mental, and role/social) of the 36-Item Short-Form Health Survey according to whether they belonged to patients in the joint-preservation or in the joint-replacement groups.

RESULTS

The survey response rate was 67.7%. MSTS and TESS scores were higher in the patients in the joint-preservation group than in the joint-replacement group, although the differences lacked statistical significance.

CONCLUSION

Better physical outcomes improve patient satisfaction, as demonstrated by the high satisfaction in the group with joint-preservation.

Risk factors for surgical site infection after malignant bone tumor resection and reconstruction

BACKGROUND

Use of an implant is one of the risk factors for surgical site infection (SSI) after malignant bone tumor resection. We developed a new technique of coating titanium implant surfaces with iodine to prevent infection. In this retrospective study, we investigated the risk factors for SSI after malignant bone tumor resection and to evaluate the efficacy of iodine-coated implants for preventing SSI.

METHODS

Data from 302 patients with malignant bone tumors who underwent malignant bone tumor resection and reconstruction were reviewed. Univariate analyses were performed, followed by multivariate analysis to identify risk factors for SSI based on the treatment and clinical characteristics.

RESULTS

The frequency of SSI was 10.9% (33/302 tumors). Pelvic bone tumor (OR: 4.8, 95% CI: 1.8-13.4) and an operative time ≥ 5 h (OR: 3.4, 95% CI: 1.2-9.6) were independent risk factors for SSI. An iodine-coated implant significantly decreased the risk of SSI (OR: 0.3, 95% CI: 0.1-0.9).

CONCLUSION

The present data indicate that pelvic bone tumor and long operative time are risk factors for SSI after malignant bone tumor resection and reconstruction, and that iodine coating may be a promising technique for preventing SSI.

Score-Based and Nutrient-Derived Dietary Patterns Are Associated with Depressive Symptoms in Community-Dwelling Older Japanese: A Cross-Sectional Study

OBJECTIVES

This study evaluated associations of score-based and nutrient-derived dietary patterns with depressive symptoms in community-dwelling older Japanese.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

982 community-dwelling adults aged 65 years or older.

MEASUREMENTS

Score-based pattern was assessed by using dietary variety score (DVS), which covers 10 food group items in Japanese meals. Nutrient-derived dietary patterns were identified by using reduced rank regression (RRR), with folate, vitamin C, magnesium, calcium, iron, and zinc intakes as response variables. Depressive symptoms were assessed with the Geriatric Depression Scale. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these dietary patterns in multivariate logistic regression analyses with potential confounders. The lowest consumption category was used as the reference group.

RESULTS

The prevalence of depressive symptoms was 13.5%. Higher DVS was associated with fewer depressive symptoms (OR=0.52, 95% CI=0.27-1.03 for the highest vs the lowest DVS; P for trend=0.031). The first RRR dietary pattern score was characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruits, and green tea and a low intake of rice and was inversely associated with the prevalence of depressive symptoms (OR=0.53, 95% CI=0.30-0.92; P for trend=0.030).

CONCLUSION

Greater dietary variety and a dietary pattern characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruit, and green tea and a low intake of rice were consistently associated with lower prevalence of depressive symptoms in community-dwelling older Japanese. Therefore, both patterns identified the components of dietary habits essential to depression prevention.

The usefulness of wide excision assisted by a computer navigation system and reconstruction using a frozen bone autograft for malignant acetabular bone tumors: a report of two cases

Background

Difficult resection of tumors from regions with complex local anatomy, such as the pelvis and sacrum, is likely to result in inadequate surgical margins (intralesional or marginal); this is because three-dimensional osteotomy is difficult particularly around the acetabulum. Additionally, removal of the joint makes reconstruction very difficult; thus, retention of good function also becomes difficult. In musculoskeletal oncology, computer navigation systems are still not widely used to prevent tumor-positive margins. We performed wide excision with guidance from a computer navigation system and reconstruction using frozen bone autografts for malignant pelvic bone tumors in two patients, and we obtained excellent functional and oncological outcomes. Here we present these patients and discuss our approach.

Case presentation

Case 1: A 12-year-old girl presented with Ewing sarcoma of the left pelvis (PI-II). We performed wide excision assisted by a computer navigation system with the osteotomy of the load surface of acetabulum and reconstruction using a frozen bone autograft. At the final follow-up, she showed excellent function and was alive without the disease. Moreover, she did not have osteoarthritis of the left hip joint.

Case 2: A 71-year-old woman presented with dedifferentiated chondrosarcoma of the right pelvis (PII-III). We performed wide excision assisted by a computer navigation system with osteotomy avoiding load surface of the acetabulum and reconstruction using a frozen bone autograft; there was no tumor at the load surface. At the final follow-up, she showed good function, was alive without the disease, and did not have osteoarthritis of the left hip joint.

Conclusions

Wide excision assisted by a computer navigation system and reconstruction using a frozen bone autograft are very useful for the management/treatment of extremely difficult cases such as malignant pelvic bone tumors, particularly those including the acetabulum.

Efficacy of radio-hyperthermo-chemotherapy as salvage therapy for recurrent or residual malignant soft tissue tumors

BACKGROUND

Recurrence after wide excision or residual tumor after an unplanned excision of a malignant soft tissue sarcoma (STS) is a complex problem, due to a higher recurrence rate and poorer survival rate compared with primary resection. Regional hyperthermia was used, with the expectation that it will enhance the anti-tumor effects of chemotherapy and radiotherapy. This study aimed to assess the efficacy of neoadjuvant concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for salvage of recurrent or residual malignant STS.

METHODS

We identified 64 patients with recurrent or residual STS treated between 1994 and 2013. After excluding those with low-grade malignancy, with recurrent bone tumor in the soft tissues, with truncal STS, and who declined to participate, 23 patients (7 with recurrence and 16 with residual tumor) underwent RHC. The histologic diagnoses were undifferentiated pleomorphic sarcoma (n = 11), synovial sarcoma (n = 3), leiomyosarcoma and myxoid liposarcoma (n = 2 each), and other histologic types. As primary outcomes, the 5-year overall survival (OS), distant metastasis-free survival (D-MFS), and local control (LC) rates were evaluated by Kaplan-Meier analysis.

RESULTS

The median follow-up period was 112.3 months. The 5-year OS, D-MFS, and LC were 86.4%, 77.4%, and 86.7%, respectively. In the univariate analysis, tumor depth was considered as a negative prognostic factor for OS and D-MFS, and a positive margin was also a negative prognostic factor for OS, D-MFS LC with retained on Cox proportional hazards model in OS, and D-MFS.

CONCLUSION

RHC is an effective option for salvage treatment of recurrent and residual STS.

Albumin, Hemoglobin, and the Trajectory of Cognitive Function in Community-Dwelling Older Japanese: A 13-Year Longitudinal Study

BACKGROUND

Cognitive function can substantially decline over a long period, and understanding the trajectory of cognitive function is important. However, little is known about the linkage between nutritional biomarkers and long-term cognitive change.

OBJECTIVES

We analyzed 13-year longitudinal data for older Japanese to examine the associations of serum albumin and hemoglobin levels with the trajectory of cognitive function.

DESIGN

Longitudinal study.

SETTING

Community-based.

PARTICIPANTS

A total of 1,744 community-dwelling adults aged 65 years or older who participated in annual health examinations in Kusatsu town, Gunma Prefecture, Japan, from 2002-2014.

MEASUREMENTS

Cognitive function was assessed annually by the Mini-Mental State Examination (MMSE). Albumin and hemoglobin levels at baseline (the year when a respondent first participated in the health examination) were divided into quartiles. Hierarchical linear modeling was used to analyze intrapersonal and interpersonal differences in cognitive function.

RESULTS

Participants' MMSE scores decreased at an accelerated rate over the 13-year period. Participants with the lowest baseline albumin level (below the first quartile line) showed a greater accelerated decline in MMSE scores over time, compared with those with the highest level (above the third quartile line). Moreover, MMSE scores in participants with a lower hemoglobin level and lower MMSE score at baseline tended to decline faster over time at an accelerated rate.

CONCLUSIONS

These findings yield new insights about the complex and diverse roles of these nutritional biomarkers on the trajectory of cognitive function in old age.