Association Between Catheter Ablation and Dementia Among Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis

Atrial fibrillation (AF) is associated with an increased risk of Dementia. However, the association between catheter ablation (CA) in patients with atrial fibrillation and the risk of dementia is not well established, with conflicting results to date. We aimed to evaluate the association between CA patients and the risk of Dementia. We performed a systematic literature search using the PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until 10th May 2023. Hazard ratios (HR) were pooled using a random-effect model, and a P-value of < 0.05 was considered statistically significant. A total of 5 studies with 125,649 patients (30,192 in the CA group and 95,457 in the non-CA group) were included. The mean age of patients among CA and non-CA groups was comparable (58.7 vs 58.18). The most common comorbidity among CA and non-CA groups was hypertension (18.49% vs 81.51%), respectively. Pooled analysis of primary outcome showed that CA was associated with a significant reduction in the risk of Dementia (HR, 0.63 [95% CI: 0.52-0.77], P < 0.001). Similarly, pooled analysis of secondary outcomes showed that the patients with CA had a lower risk of Alzheimer's disease (HR, 0.78 [95% CI: 0.66-0.92], P < 0.001) compared with the non-CA group. However, there was no statistically significant difference in the risk of vascular dementia (HR, 0.63 [95% CI: 0.38-1.06], P = 0.08) between both groups of patients. Our study suggested that catheter ablation reduced the risk of dementia and Alzheimer's disease compared to the nonablation group of patients.

Post-diagnostic statin use and its association with cancer recurrence and mortality in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Statins are widely acknowledged for their application in patients with hypercholesterolemia to reduce cardiovascular morbidity and mortality. More recently, their potential to exert pleiotropic effects, particularly in impeding the proliferation of neoplastic cells, has attracted considerable attention. Prior studies have demonstrated that statins may mitigate cancer progression and micrometastasis. However, the benefits of statins in breast cancer have been inconclusive.

OBJECTIVE

The aim of this meta-analysis was to evaluate the impact of statin use following a breast cancer diagnosis on breast cancer recurrence and mortality.

METHODS

We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until 30th May 2023. Hazard ratios (HR) were pooled using a random-effect model. The primary outcome of interest was the risk of breast cancer recurrence. The secondary outcomes included breast cancer-specific mortality and all-cause mortality.

RESULTS

A total of 15 studies with 156 448 patients were included in the final analysis. The mean age of patients between statin users and non-users was 64.59 and 59.15 years, respectively. Statin use was associated with a reduction in the recurrence of breast cancer [HR 0.76, 95% confidence interval (CI): 0.67-0.87] compared with non-statin users. This trend was similar among lipophilic statin users (HR 0.73, 95% CI: 0.63-0.85) but not for hydrophilic statin users (HR 1.17, 95% CI: 0.82-1.68). Furthermore, statin users exhibited a lower risk of breast cancer mortality (HR 0.80, 95% CI: 0.66-0.96) but all-cause mortality (HR 0.82, 95% CI: 0.66-1.02) was comparable among both groups of patients. Conversely, lipophilic statins demonstrated a reduction in both all-cause mortality (HR 0.84, 95% CI: 0.75-0.93) and breast cancer mortality (HR 0.85, 95% CI: 0.74-0.99) compared to non-statin users.

CONCLUSION

Among patients with breast cancer, statin use post-diagnosis decreases the risk of breast cancer recurrence and breast cancer mortality. Furthermore, lipophilic statins exhibit an additional advantage of reduction in all-cause mortality.PROSPERO registration: CRD42022362011.

SGLT2 inhibitors among patients with heart failure with preserved ejection fraction: A meta-analysis of randomised controlled trials

BACKGROUND

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been recommended in the practice guidelines for the treatment of patients with heart failure with reduced ejection fraction; however, their effects among patients with preserved ejection fraction have been debatable.

OBJECTIVE

We aim to evaluate the SGLT2 inhibitor effect among patients with heart failure with reduced ejection fraction, including DELIVER and EMPEROR-Preserved trials.

METHODS

We performed a systematic literature search using the PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until August 30th, 2022. Statistical analysis was performed by calculating hazard ratio (HR) using the random effect model with a 95% confidence interval (CI) and probability value (P). Statistical significance was met if 95% CI does not cross numeric "1" and P < .05.

RESULTS

Six studies with a total of 15,989 total patients were included in the final analysis. The mean age of patients enrolled in SGLT2 inhibitors and placebo was 69.13 and 69.37 years, respectively. The median follow-up duration was 2.24 years. SGLT2 inhibitors reduced composite cardiovascular mortality or first hospitalization for heart failure (HR, 0.80 [95% CI: 0.74-0.87], P < .001, I2 = 0%), heart failure hospitalization (HR, 0.74 [95% CI: 0.67-0.82], P < .001, I2 = 0%) compared with placebo. However, all-cause mortality (HR, 0.97 [95% CI: 0.89-1.06], P = .54, I2 = 0%) and cardiovascular mortality (HR, 0.96 [95% CI: 0.82-1.13), P = .66, I2 = 35.09%] were comparable between both groups.

CONCLUSION

Our study finding shows that SGLT2 inhibitors significantly reduced the risk of first HF hospitalization or cardiovascular death and HF hospitalization; however, all-cause mortality was comparable between the groups.

Association between heart failure and the incidence of cancer: a systematic review and meta-analysis

Aims

The association between heart failure (HF) patients and the incidence of cancer is not well understood, with conflicting results to date. The aim of this meta-analysis was to evaluate whether patients with HF have a higher risk of developing cancer.

Methods and results

We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until 10 December 2022. The primary clinical outcome was the incidence of cancer. Secondary endpoints were the incidence of breast cancer, lung cancer, haematological cancer, colorectal cancer, and prostate cancer. A total of 9 articles with 7 329 706 (515 041 HF vs. 6 814 665 non-HF) patients were involved in the analysis. The mean age of the patients in the HF and the non-HF groups was 69.06 and 66.76 years. The median follow-up duration was 6.7 years. The most common comorbidity among both groups includes diabetes mellitus (27.58 vs. 14.49%) and hypertension (81.46 vs. 57.38%). Patients with HF were associated with a significant increase in the incidence of cancer {hazard ratio [HR], 1.43 [95% confidence interval (CI): 1.21-1.68], P < 0.001}, breast cancer [HR, 1.28 (95% CI: 1.09-1.50), P < 0.001], lung cancer [HR, 1.89 (95% CI: 1.25-2.85), P < 0.001], haematological cancer [HR, 1.63 (95% CI: 1.15-2.33), P = 0.01], and colorectal cancer [HR, 1.32 (95% CI: 1.11-1.57), P < 0.001] compared with patients without HF. However, the incidence of prostate cancer was comparable between both groups [HR, 0.97 (95% CI: 0.66-1.43), P = 0.88].

Conclusion

This meta-analysis confirms that the state of HF is associated with a higher risk for incident cancer. These data may aid in raising awareness with physicians that cancer may develop in patients with prevalent heart failure and that early screening and evaluation may be useful in an early diagnosis of cancer.

Racial Disparity Among the Clinical Outcomes Post-Myocardial Infarction Patients: A Systematic Review and Meta-analysis

The clinical outcomes post-Myocardial Infarction (MI) between Black and White patients have not been well studied, with limited literature available. We conducted a meta-analysis to estimate the clinical outcomes between Black and White patients post-MI.We systematically searched the PubMed, Embase, and Scopus databases from inception until September 26, 2022. A total of 6 studies with 220,984 patients have been included in the analysis. The mean age of patients with White and Black race was 68.46 and 65.14 years, respectively. The most common comorbidity among White and Black patients was hypertension (53% vs 87.73%). Our analysis showed that the likelihood of all-cause mortality (OR, 0.71[95%CI: 0.56-0.91]), P=0.01] and stroke (OR, 0.74[95%CI: 0.67-0.81]), P<0.001] were significantly lower in white patients compared with black patients. However, Black patients had fewer utilization of CABG (OR, 1.38[95%CI: 1.19-1.62], P<0.001]) and PCI (OR, 1.31[95%CI: 1.101-1.68]), P=0.04] compared with White patients, while 30-day mortality was comparable between both the groups. To our knowledge, this is the first meta-analysis with the largest sample size thus far, highlighting that Black patients are at increased risk for all-cause mortality and stroke but have lower utilization of revascularization among MI patients than White patients.

Comparison of outcome among type 2 vs type 1 myocardial infarction: a systematic review and meta-analysis

To date, there were limited studies available on myocardial infarction (MI), and consequently, the outcomes of patients with type 1 myocardial infarction (T1MI) compared to type 2 myocardial infarction (T2MI) remained inconclusive. We aimed to compare the outcomes of T1MI and T2MI patients in terms of mortality and adverse cardiovascular outcomes. We performed a systematic literature search on PubMed, Embase, and Scopus for relevant articles from inception until March 20, 2022. 341,049 patients had T1MI, while the remaining 67,537 patients had T2MI. Mean age was similar between both groups (T1MI: 67.3 years, T2MI: 71.03 years), while the proportion of females was lower in T1MI (37.81% vs 47.15%). Our analysis revealed that patients with T1MI had significantly lower odds of all-cause mortality (OR 0.45, 95% CI 0.36-0.56, p < 0.001), in-hospital mortality (OR 0.63, 95% CI 0.46-0.86, p < 0.001), 1-year mortality (OR 0.35, 95% CI 0.25-0.47, p < 0.001), and major adverse cardiovascular events (MACE) (OR 0.59, 95% CI 0.39-0.91, p = 0.02). There was no significant difference in terms of 30-day mortality (OR 0.58, 95% CI 0.25-1.36, p = 0.21), cardiovascular mortality (OR 0.95, 95% CI 0.68-1.32, p = 0.74), all-cause readmission (OR 0.84, 95% CI 0.62-1.14, p = 0.26), and readmission due to MI (OR 1.22, 95% CI 0.66-2.27, p = 0.53) between both groups. Patients with T1MI had favorable outcomes in terms of mortality and MACE compared to that of T2MI patients. Further studies should aim at determining the optimal management strategy for these high-risk patients for better patient outcomes.

Racial Disparity Between the Post-Procedural Outcomes Among Patients With Peripheral Artery Disease: A Systematic Review and Meta-analysis

The Racial disparity between the clinical outcomes post interventions among Peripheral Artery Disease (PAD) have not been well studied, with limited literature available. We conducted a meta-analysis to evaluate the post-procedure outcomes among PAD patients between Black and White race. We systematically searched all electronic databases from inception until first November 2022. The primary endpoint was major amputation within 30 days. Secondary endpoints were myocardial infarction (MI) within 30 days, mortality within 30 days, and all-cause mortality (ACM). A total of 136,395 patients were included in the analysis, with 117,177 patients of the White race and 19,218 patients of the Black race. The mean age of the patients in each group was (66.41 vs 62.75). Most common comorbidity among White and Black patients was diabetes mellitus (42.15% vs 55.90%), and hypertension (HTN) (39.53% vs 90.07%). The odds of major amputation within 30 days was significantly higher in Black patients compared to white patients (OR, 0.40 (95% CI: 0.19-0.84, P = 0.02), while the odds of MI was higher in White patients compared to Black race PAD patients (OR, 1.29, (95%CI:1.05-1.58), P < 0.02). There was no significant difference in ACM (OR, 0.97(95%CI: 0.64-1.47, P = 0.88), and mortality within 30 days (OR, 1.09(95%CI:0.77-1.53, P = 0.64) between both groups. To our knowledge, this is the first meta-analysis with the largest sample size thus far, highlighting that Black patients are at a higher risk for major amputation within 30 days compared to white patients although mortality remains comparable between the 2 races.

Early surgery vs conservative management among asymptomatic aortic stenosis: A systematic review and meta-analysis

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Aortic valve replacement remains the definitive choice of treatment for AS.

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All-cause mortality and adverse events are lower with early surgical valve repair.

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In high-risk AS patients, early surgery is safer than conservative management.

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Early intervention is crucial to prevent irreversible damage of AS.

Introduction

Although aortic valve replacement in severe symptomatic Aortic Stenosis (AS) are clearly outlined, the role of surgical intervention in asymptomatic severe AS remains unclear with limited evidence. The aim of our meta-analysis is to evaluate the efficacy and safety of early surgical aortic valve repair compared to conservative management.

Methods

A systematic literature search was performed in PubMed, Scopus, Embase and Cochrane databases for studies comparing the early surgery versus conservative management among asymptomatic aortic stenosis patients. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a p-value of < 0.05 was considered statistically significant.

Results

A total of 5 articles (3 observational studies and 2 randomized controlled trials) were included. At a median followup of 4.1 years, here were significantly lower odds of all-cause mortality [OR = 0.30 (95 %CI:0.17–0.53), p < 0.0001], cardiovascular mortality [OR = 0.35 (95 %CI:(0.17–0.72), p = 0.005], and sudden cardiac death (OR = 0.36 (95 %CI: 0.15–0.89), p = 0.03) among early surgery group compared with conservative care. There was no significant difference between incidence of major bleeding, clinical thromboembolic events, hospitalization due to heart failure, stroke and myocardial infarction between the conservative care groups and early surgery.

Conclusion

Among asymptomatic patients with AS, early surgery shows better outcomes in reducing all-cause mortality and cardiovascular mortality compared with conservative management approaches.

Echocardiographic predictors of presence of cardiac amyloidosis in aortic stenosis

AIMS

Aortic stenosis (AS) and cardiac amyloidosis (CA) frequently coexist but the diagnosis of CA in AS patients remains a diagnostic challenge. We aim to evaluate the echocardiographic parameters that may aid in the detection of the presence of CA in AS patients.

METHOD AND RESULTS

We performed a systematic literature search of electronic databases for peer-reviewed articles from inception until 10 January 2022. Of the 1449 patients included, 160 patients had both AS-CA whereas the remaining 1289 patients had AS-only. The result of our meta-analyses showed that interventricular septal thickness [standardized mean difference (SMD): 0.74, 95% CI: 0.36-1.12, P = 0.0001), relative wall thickness (SMD: 0.74, 95% CI: 0.17-1.30, P < 0.0001), posterior wall thickness (SMD: 0.74, 95% CI 0.51 to 0.97, P = 0.0011), LV mass index (SMD: 1.62, 95% CI: 0.63-2.62, P = 0.0014), E/A ratio (SMD: 4.18, 95% CI: 1.91-6.46, P = 0.0003), and LA dimension (SMD: 0.73, 95% CI: 0.43-1.02, P < 0.0001)] were found to be significantly higher in patients with AS-CA as compared with AS-only patients. In contrast, myocardial contraction fraction (SMD: -2.88, 95% CI: -5.70 to -0.06, P = 0.045), average mitral annular S' (SMD: -1.14, 95% CI: -1.86 to -0.43, P = 0.0017), tricuspid annular plane systolic excursion (SMD: -0.36, 95% CI: -0.62 to -0.09, P = 0.0081), and tricuspid annular S' (SMD: -0.77, 95% CI: -1.13 to -0.42, P < 0.0001) were found to be significantly lower in AS-CA patients.

CONCLUSION

Parameters based on echocardiography showed great promise in detecting CA in patients with AS. Further studies should explore the optimal cut-offs for these echocardiographic variables for better diagnostic accuracy.

Cardioprotective effects of Influenza Vaccination among Patients with Established Cardiovascular Disease or at High Cardiovascular Risk: A Systematic Review and Meta-analysis

BACKGROUND

The clinical impact of the influenza vaccination on cardiovascular outcomes in people with established cardiovascular disease (CVD) is still debated.

AIM

The aim of this meta-analysis was to estimate the effect of influenza vaccination on cardiovascular and cerebrovascular outcomes among patients with established CVD.

METHODS

We systematically searched all electronic databases from inception until 15 April 2022. Primary clinical outcomes were all-cause mortality (ACM), and major adverse clinical events (MACE). Secondary endpoints were heart failure, myocardial infarction, CV mortality, and stroke.

RESULTS

Eighteen articles (five randomized trials and thirteen observational studies), with a total of 22,532,165 patients were included in the analysis. There were 217,072 participants included in the high cardiovascular risk or established CVD population (vaccinated n = 111,073 and unvaccinated n = 105,999). The mean age of the patients was 68 years old, without any difference between groups (69 vs 71) years. At mean follow-up of 1.5 years, vaccinated group was associated with lower risk for all-cause mortality [HR, 0.71(95%CI, 0.63-0.80), p < 0.001], MACE [HR, 0.83(95%CI:0.72-0.96), p = 0.01], CV mortality [HR, 0.78(95%CI:0.68-0.90), p < 0.001] and myocardial infarction [HR, 0.82(95%CI:0.74-0.92), p < 0.001] compared to unvaccinated group. While incidence of stroke [HR, 1.03 (95%CI, 0.92-1.06), p = 0.61] and heart failure [HR, 0.74 (95%CI, 0.51-1.08), p = 0.12] did not differ between the two groups.

CONCLUSION

Influenza vaccination reduced major adverse clinical events, all-cause mortality, CV mortality and myocardial infarction. These highlighted the importance of influenza vaccination in established CVD or high cardiovascular risk.

1011 CONTINUUM OF GERIATRIC CARE FOR OLDER ADULTS WITH DUAL SENSORY LOSS DURING THE COVID-19 PANDEMIC IN CANADA: LESSONS LEARNED

Introduction

Around 1.1 million older Canadians live with combined hearing and vision impairment (dual sensory loss/DSL). Evidence highlights that they are at a high risk of cognitive impairment, functional decline, social isolation, falls, depression, and mortality. Compared to their non-DSL peers, older adults with DSL experience various challenges in accessing healthcare, which were exacerbated during the COVID-19 pandemic. This study aimed to explore the continuum of geriatric care for older adults with DSL by integrating their perspectives, those of caregivers who accompany them on healthcare visits, and their healthcare providers in Canada during the pandemic.

Method

We conducted a qualitative study with 32 older Canadians with DSL and their caregivers, and an online survey with 228 healthcare providers across the country. Qualitative interviews were audio-recorded using Zoom and transcribed verbatim, while the survey data were collected using Lime Survey. Thematic analysis was used to analyse qualitative data, whereas descriptive statistics were used for quantitative survey data.

Results

The findings highlighted the gaps in the continuum of care for this population. The reported gaps were lack of training on DSL among healthcare providers, lack of time and comfort to go beyond one’s specialty, lack or limited support to overcome communication challenges while providing care to older adults with DSL, difficulty in using technologies for virtual/telehealth, presence of comorbidities such as cognitive impairment, and restrictions in caregiver accompaniment during the pandemic.

Conclusion

Our findings indicate that the continuum of care for this group is negatively affected due to the pandemic, in a disproportionate manner, and structural barriers are experienced by older adults with DSL and their caregivers for access to care. To ensure effective care, healthcare professionals need training on DSL-specific accessibility and communication. A collaborative, cross-disciplinary geriatric care approach with the active involvement of essential care partners is an utmost need.

Hypovitaminosis D and cardiovascular outcomes: A systematic review and meta-analysis

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Vitamin D deficiency can not only affect bones but have association with cardiovascular effects.

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The likelihood of unfavorable cardiovascular outcomes, especially major adverse cardiovascular event (MACE), new MI, and all-cause mortality among deficient vitamin D patient is poorly understood.

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This is a first and most comprehensive meta-analysis with the largest sample size thus far comparing vitamin D levels in terms of cardiovascular outcomes.

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High risk patients need to monitor vitamins level and implement vitamins supplementation to avoid adverse outcomes especially elder females.

Background

Methods

Results

Conclusions

Symptomatology, prognosis and clinical findings of STEMI as a ramification of COVID-19: A systematic review and proportion meta-analysis

Background

There is an increasing COVID-19 population with concurrent STEMI. SARS-CoV-2 poses a significant risk of hypercoagulable and/or prothrombotic events due to the disturbance in hemostasis by affecting all three components of the Virchow's triad. These abnormalities in hemostasis are an increased risk factor for cardiovascular events, including acute thrombotic occlusion of coronary arteries leading to myocardial infarction.

Objective

The objective of this study is to collate the prognosis, symptomatology and clinical findings of COVID-19 adverse events causing STEMI.

Methods

Databases were queried with various keyword combinations to find applicable articles. Cardiovascular risk factors, symptomatology, mortality and rates of PCI were analyzed using random-effect model.

Results

15 studies with a total of 379 patients were included in the final analysis. Mean age of patients was 62.82 ± 36.01, with a male predominance (72%, n = 274). Hypertension, dyslipidemia and diabetes mellitus were the most common cardiovascular risk factors among these patients, with a pooled proportion of 72%, 59% and 40% respectively. Dyspnea (61%, n = 131) was the most frequent presenting symptom, followed by chest pain (60%, n = 101) and fever (56%, n = 104). 62% of the patients had obstructive CAD during coronary angiography. The primary reperfusion method used in the majority of cases was percutaneous coronary intervention (64%, n = 124). Mortality, which is the primary outcome in our study, was relatively high, with a rate of 34% across studies.

Conclusion

Our findings show that most cases have been found in males, while the most common risk factors were Hypertension and Diabetes Mellitus. In most COVID-19 cases with ST-segment myocardial infarction, most hospitalized patients underwent primary percutaneous coronary intervention instead of fibrinolysis. The in-hospital mortality was significantly higher, making this report significant. As the sample size and reported study are considerably less, it warrants a further large-scale investigation to generalize it.

Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review

Introduction:

COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination.

Methods:

This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients’ baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data.

Result:

The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age (P = .733), sex (P = .095), vaccine type (P = .798), platelet count (P = .93), and comorbidities such as hypertension (P = .734) and diabetes mellitus (P = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination (P = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant (P = .039). Patients who developed intracranial hemorrhage (P = .012) or thrombosis in the cortical vein (P = .021) were more likely to die.

Conclusion:

COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.

Symptomatology, prognosis, and clinical findings of COVID 19 induced myocarditis: a systematic review

Background

With the advent of the novel coronavirus (COVID-19) in December 2019, numerous case studies have been reported on its impact on cardiac cells, and we purpose to perform a systematic review that explains the symptomatology, prognosis, and clinical findings of COVID-19-related myocarditis patients.

Methods

PRISMA guidelines were employed and peer–reviewed journals in English related to COVID – 19 were included. Exclusion criteria included &lt;50 y, known heart problems. Age criteria was guided by prior systematic report by Kariyanna et al (2020). Search engines included Pubmed, Google scholar, Cochrane Central and Web of Science database using “SARS-CoV-2” or “COVID 19” and “myocarditis”. The data were analyzed and synthesized qualitatively using MS Excel PIVOT and quality was rated using the “Research and Quality Scoring Method” by Sackett and Haynes, the Jadad scale, and the items published by Cho and Bero (Han et al., 2011).

Results

A total of 22 studies on 37 patients were included; 6 were confirmed myocarditis while the rest have possible myocarditis. Among all these 62% were male and showing dominance. The most common presenting symptoms appear to be fever, chest pain, shortness of breath, and cough. Most of the patients have shown elevation in cardiac biomarkers (troponin levels, CRP, CK level, CK-MB, NT-pro BNP). Electrocardiogram changes include sinus rhythm, tachycardia, and non specific ST - segment elevation and T wave changes. Echocardiography results commonly found were left ventricular dysfunction and increased wall thickness. CMR was performed in 8 patients, with features of reduced ejection fraction, myocardial edema, and hypokinesia, whereas biopsy has been performed among 3 patients due to the invasive nature of the procedure and common findings include inflammatory biomarkers were raised. Overall Prognosis appears to be bad in which 25% of patients were not able to survive and 75% of them were recovered.

Conclusions

Myocarditis-related COVID-19 mortality continues to be high and under-estimated. The patient manifestations are identical and difficult to distinguish from COVID-19-related symptoms. Just a limited number of patients undergo confirmatory tests, such as an MRI or an endomyocardial biopsy, which may not be available. Further studies are needed to confirm and quantify the actual prognosis and outcomes of patients with COVID-19 myocarditis. Moreover, available data on the usage of glucocorticoids in the coronavirus infection is controversial to our knowledge. Corticosteroid therapy is unsuccessful in the treatment of viral myocarditis, according to a Cochrane systematic review conducted in 2013. It also allows viral clearance to be overdue. Corticosteroids, on the other hand, reduce the chance of mortality for ICU patients in Wuhan. To concede, more studies, clinical trials, and duration is needed for a thorough understanding of COVID – 19, and its impact on cardiac health

Funding Acknowledgement

Type of funding sources: Other.

The use of SPECT/CT quantification of 99mTc-PYP uptake to assess tafamidis treatment response in ATTR cardiac amyloidosis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Nuclear scintigraphy with bone-avid radiotracers such as Tc-99m-PYP, Tc99m-DPC and Tc-99m-HMDP are used to diagnose transthyretin (ATTR) cardiac amyloidosis with limited quantification employing a semi-quantitative visual score and a heart to contralateral lung ratio. Therapy for ATTR cardiac amyloid currently is limited to a single FDA approved agent, tafamidis, however, there is no data regarding the longitudinal assessment of imaging findings in patients undergoing therapy. SPECT/CT acquisition and analysis with dedicated software can provide volumetric assessment and quantification of cardiac tracer uptake.

Purpose

The purpose of this study was to perform longitudinal assessment of cardiac ATTR amyloid 99mTc-PYP imaging findings to determine if treatment with tafamidis results in any change in quantitative measures of tracer uptake. There is no data on if treatment results in a decrease in cardiac amyloid burden as assessed by 99mTc-PYP imaging.

Methods

A prospective, single center, study of patients with ATTR cardiac amyloid being treated with tafamidis (either 80mg or 61mg dose) who have baseline and follow-up 99mTc-PYP studies. SPECT/CT quantification software was used to quantify heart, lung, and bone tracer uptake and generate standardized uptake values (SUVs). Comparison of baseline (before treatment) total SUVs, mean SUV value, percentage of the injected dose, mean SUV of heart to mean SUV of bone ratio and to mean SUV of right lung ratio was made to the values obtained at follow-up after tafamidis treatment. Measurements were obtained from the whole heart and the isolated left ventricle. Data was obtained by two physicians and the results averaged.

Results

5 patients were analyzed with a mean age 73.8 ± 7.7, 80% were males, and a mean length of tafamidis therapy at repeat imaging of 12.5 ± 3.8 months. At follow-up there was an average decrease in whole heart total SUV counts by -25.9 ± 10.3%, in the mean SUV value by -18.2 ± 18.2% and in the percentage of injected dose by -23.7 ± 14.0%. Similar decreases were seen in the isolated left ventricle measures. Heart to bone and heart to lung ratios showed a mixed response to therapy. Detailed results are provided in the table.

Conclusion

The measurements of total SUV counts, mean SUV value, and percentage of the injected dose showed improvement with tafamidis treatment. The ratios did not uniformly show improvement and the reason for this finding is unclear. This new technique offers a potential method for following tafamidis therapy and assessing the cardiac amyloid burden.

Metabolic Profile of Lean/Non Obese NAFLD (Non Alcoholic Fatty Liver Disease) Subjects

Introduction: Non Alcoholic Fatty Liver Disease (NAFLD) in the absence of overweight and obesity has been defined as ‘lean NAFLD’. Metabolic syndrome associated diseases in low and middle income countries have variable phenotypes and clinical outcomes. Hypothetically, ‘Lean NAFLD’ can be a part of the spectrum of classical obesity related NAFLD or separate entity with different pathophysiology. Aim: 1) To characterise the NAFLD in lean/non obese subjects; 2) To explore how it differs from classical ‘obese phenotype’ of the NAFLD; 3) To explore how these lean/non obese subjects with NAFLD are different from healthy lean/non obese subjects in terms of metabolic profile. Materials and Methods: The present study was a cross- sectional observational study conducted over a period of six months. Forty subjects were categorised into four groups (1. Lean NAFLD without Diabetes; 2. Lean NAFLD with Diabetes; 3. Obese NAFLD with Diabetes; 4. Lean healthy subjects). Clinical history, examination, anthropometry, biochemical data including insulin resistance by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) were analysed. Results: Mean Body Mass Index (BMI), Fasting Blood Glucose (FBG) and HbA1c (Glycated haemoglobin) of group 2 and group 3 were significantly higher than that of group 1 and group 4 subjects (p<0.001). Mean HOMA-IR of the patients of group 2 and group 3 were significantly higher than that of group 1 and group 4 (p<0.001). No significant difference was seen in HOMA- IR between patients of group 1 and group 4 (p>0.05) and also of group 2 and group 3 subjects (p>0.05). Conclusion: Lean NAFLD subjects have a different metabolic profile than overweight-obese patients with NAFLD, particularly in relation to diabetes. On the basis of all metabolic parameters and insulin resistance, authors propose a spectrum of insulin resistance ‘Non obese Control - Non obese NAFLD without Diabetes Mellitus (DM) - Non obese NAFLD with DM - Obese NAFLD with DM’.

Bouveret’s Syndrome- An Uncommon Variant of Gallstone Ileus: Case Series and Review of Literature

Bouveret’s syndrome is a rare form of gallstone ileus. It refers to gastric outlet or small bowel obstruction caused by the formation of a biliary enteric fistula with subsequent migration and impaction of a large gallstone into stomach or small intestine. Its diagnosis is often delayed or overlooked. Diagnosis is based on the clinical manifestations, presence of pneumobilia, visualisation of stone and demonstration of small bowel obstruction on imaging. Enterotomy or gastrotomy with or without cholecystectomy and fistula repair is the most common surgical therapy. The aim of this case series was to analyse the presentation of Bouveret’s syndrome and strategise the optimum surgical approach based on the available literature and authors experience. Authors hereby report three cases of Bouveret’s syndrome encountered within last two years with clinical presentation, surgical approaches and operative findings. Computed Tomography (CT) scan is most commonly used to diagnose this rare entity. Early detection and optimum timing of surgery plays crucial role in outcome. It has high success rate, with acceptable surgical morbidity and mortality. Heightened awareness of this syndrome may lead to decreased morbidity and mortality.

COVID-19 Infection and Myocarditis: A State-of-the-Art Systematic Review

BACKGROUND

COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well. COVID-19 may lead to cardiovascular injuries, resulting in myocarditis, with inflammation of the heart muscle.

OBJECTIVE

This systematic review collates current evidence about demographics, symptomatology, diagnostic, and clinical outcomes of COVID-19 infected patients with myocarditis.

METHODS

In accordance with PRISMA 2020 guidelines, a systematic search was conducted using PubMed, Cochrane Central, Web of Science and Google Scholar until August, 2021. A combination of the following keywords was used: SARS-CoV-2, COVID-19, myocarditis. Cohorts and case reports that comprised of patients with confirmed myocarditis due to COVID-19 infection, aged >18 years were included. The findings were tabulated and subsequently synthesized.

RESULTS

In total, 54 case reports and 5 cohorts were identified comprising 215 patients. Hypertension (51.7%), diabetes mellitus type 2 (46.4%), cardiac comorbidities (14.6%) were the 3 most reported comorbidities. Majority of the patients presented with cough (61.9%), fever (60.4%), shortness of breath (53.2%), and chest pain (43.9%). Inflammatory markers were raised in 97.8% patients, whereas cardiac markers were elevated in 94.8% of the included patients. On noting radiographic findings, cardiomegaly (32.5%) was the most common finding. Electrocardiography testing obtained ST segment elevation among 44.8% patients and T wave inversion in 7.3% of the sample. Cardiovascular magnetic resonance imaging yielded 83.3% patients with myocardial edema, with late gadolinium enhancement in 63.9% patients. In hospital management consisted of azithromycin (25.5%), methylprednisolone/steroids (8.5%), and other standard care treatments for COVID-19. The most common in-hospital complication included acute respiratory distress syndrome (66.4%) and cardiogenic shock (14%). On last follow up, 64.7% of the patients survived, whereas 31.8% patients did not survive, and 3.5% were in the critical care unit.

CONCLUSION

It is essential to demarcate COVID-19 infection and myocarditis presentations due to the heightened risk of death among patients contracting both myocardial inflammation and ARDS. With a multitude of diagnostic and treatment options available for COVID-19 and myocarditis, patients that are under high risk of suspicion for COVID-19 induced myocarditis must be appropriately diagnosed and treated to curb co-infections.

Abstract P2-06-25: A phenotypic screening and machine learning platform efficiently identifies triple negative breast cancer-selective and readily druggable targets

Identifying effective oncogenic targets is challenged by the complexity of genetic alterations in cancer and their poorly understood relation to cell function and survival. This, combined with the fact that the majority of the proteome is predicted to be undruggable, may explain why genomic approaches have had only moderate success in identifying and translating oncogenic drug targets. There is a need for methods that rapidly and accurately identify “pharmacologically effective” targets without the requirement for priori knowledge of complex signaling networks. We developed an approach that uses machine learning to relate results from unbiased phenotypic screening of kinase inhibitors to their biochemical activity data. This process, which we call idTRAX (Identification of Drug TaRgets and Anti-targets by Cellular and Molecular Cross-referencing), identifies targets that are pharmacologically responsive and readily druggable. Additionally, the identified targets are not typically overcome by the robustness of signaling networks, because only targets that effectively induce a phenotype upon pharmacological engagement are selected. We applied this methodology to triple negative breast cancer, which still lacks targeted therapy. We screened 19 breast cancer cell lines with ˜500 small-molecule kinase inhibitors with annotated kinase activity data and identified cell-line specific kinase targets, i.e. kinases whose inhibition causes cell line-specific cytotoxicity or cytostaticity. We were able to identify various unique cell line selective kinase addictions along with well-known driver kinase addictions, for example, dependence on FGFR2 in the MFM-223 cell line and AKT kinases in MFM-223, CAL-148, and others. We also found that triple negative breast cancer cell lines exhibit heterogeneous target patterns, indicating the need of personalized medicine approach to tackle them. We further compared candidate targets identified by idTRAX with those reported from RNAi- and CRISPR-based screens. Strikingly, the correlation between targets identified by the pharmacological approach and those identified by knockdown/knockout-based screens was low [average rank correlation (ρ) = 0.0273- 0.1074], suggesting that gene-silencing approaches may not be the most efficient at identifying targets for small-molecule drug discovery or repurposing. Our approach provides a platform for rapidly identifying sample-specific drug targets and potentially guiding personalised therapy regimens.

Citation Format: Gautam P, Jaiswal A, Aittokallio T, Hassan A-A, Wennerberg K. A phenotypic screening and machine learning platform efficiently identifies triple negative breast cancer-selective and readily druggable targets [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-06-25.

Evaluation of Surface Roughness of Nanofilled Composite Restorations after Simulated Tooth Brushing using Various Dentifrices

Background Teeth restored with direct composite resin are constantly exposed to specific challenges of the oral cavity. These challenges can modify the material properties and, when associated with daily brushing, eventually change its surface roughness, allowing bacterial growth and retention of extrinsic pigments. Dentifrices plays an important role in dental wear (abrasion) and over time, can also cause an increase in the surface roughness of restorative materials. Objective To assess the effect of dentifrices on the longevity of direct nanofilled composite resins restorations as far as wear and roughness is concerned. Method Class V cavity were prepared on 90 extracted human teeth and restored with Filtek Z350 composite. Teeth were randomly divided into 6 experimental groups of 15 each labelled as Group-1 (Colgate Dental cream) Group-2 (Colgate Active Salt toothpaste), Group-3 (Pepsodent Regular toothpaste), Group-4 (Dabur red toothpaste), Group-5 (Dabur Lal tooth powder) and Group-6 Control (water). The samples were fixed on tooth brushing machine and subjected to mechanical tooth brushing using various dentifrices according to respective groups in 3 phases and reading of surface roughness (Ra) was recorded. Result Surface roughness (Ra) had increased in following order: Group 6 < Group 3 < Group 2 < Group 1 < Group 4 < Group 5. All the tooth pastes were compared, their behaviour was found to be similar as there was no statistically significant difference amongst them. Though all of them were inferior to control group and the difference was statistically significant. Whereas the only tooth powder Dabur lal tooth powder gave the maximum roughness when compared with the other tooth pastes and the difference was statistically significant. Conclusion With increase in time of brushing there was increase in surface roughness in all the 5 dentifrices among them Ra was maximum for Dabur lal tooth powder.

The clinical utility of cycle of threshold value of GeneXpert MTB/RIF (CBNAAT) and its diagnostic accuracy in pulmonary and extra-pulmonary samples at a tertiary care center in India

BACKGROUND

There are knowledge gaps in the in-depth analysis of the most promising and robust diagnostic tool, GeneXpert MTB/RIF (CBNAAT). The cycle of threshold (CT) value of the CBNAAT test and its clinical implications has not been explored much.

AIMS AND OBJECTIVES

The study aimed at (a) estimating the diagnostic accuracy and incremental yield of Xpert MTB/RIF in various specimens (b) establishing the association between CT value category (high, medium, low, very low) and culture time-to-positivity (TTP).

METHODS

A total of 1000 samples, both pulmonary and extra-pulmonary were collected from presumptive TB cases in a large tertiary care hospital. Sensitivity and specificity of CBNAAT was calculated with culture as the gold standard. The association of CT value with culture TTP was also studied.

RESULTS

The overall sensitivity of CBNAAT was 88.5%, with bronchial washing specimen being the most sensitive (92.3%) and pleural fluid being the least (66.7%). In smear negative individuals, the sensitivity of CBNAAT was 80.9%. The additional yield of CBNAAT over smear microscopy was 10.9%. It was observed that as we move from high to very low CT category, culture positivity decreases significantly (p<0.001), whereas time taken for culture growth increases (p<0.001).

CONCLUSION

CBNAAT is a robust test for accurate diagnosis of tuberculosis both pulmonary and extra-pulmonary, smear negative as well, especially in resource-limited settings. The correlation between CT value and culture TTP has potential in predicting bacillary load, though further studies are required.

Revision shoulder arthroplasty for failed surface replacement hemiarthroplasty

PURPOSE

The aim of this study was to assess the reasons of failure of shoulder surface replacement hemiarthroplasty (SRH) and to evaluate the outcome of revision surgery.

METHOD

The study group included 25 patients (26 shoulders) with failed SRHs. The mean time to revision surgery was 3.6 years. Their functional outcome was evaluated using adjusted Constant-Murley score at mean follow-up of 5.2 years (range 2-16 years).

RESULT

Most common cause of failure was glenoid erosion (42%) and progressive failure of rotator cuff (31%). Median adjusted Constant-Murley score at mean follow-up of 5.2 years was 51.6. Median adjusted Constant-Murley score in patients who had primary diagnosis of osteoarthritis and had revision performed to anatomic TSA (14 shoulders) was 85 (range 40-100) at mean follow-up of 5 years compared to 36.3 (range 20-66.3) in the remaining patients at 5.4 years, p = 0.00008.

CONCLUSION

Revision surgery for failed SRH can be technically challenging with variable results. Most common mode of failure was glenoid erosion. Functional outcomes are better in those with revision performed to anatomic TSA.

Efficacy and Safety of Cyclosporine versus Tacrolimus in Steroid and Cyclophosphamide Resistant Nephrotic Syndrome: A Prospective Study

Calcineurin inhibitors (CNIs) are the preferred drugs for treatment of childhood steroid-resistant nephrotic syndrome (SRNS) who are also resistant to cyclophosphamide (CYC). Although few studies have shown a benefit of one over the other, efficacy and safety of either CNIs (tacrolimus [TAC] or cyclosporine [CSA]) in this special population remained to be assessed in long-term studies. Forty-five children with SRNS who were also resistant to CYC (CYC-SRNS) from January 2006 to June 2011, were included in the study. Patients were treated with CNI either TAC or CSA based on 1:1 allocations and were prospectively observed. Patients who were nonresponsive to CNIs had been treated with mycophenolate mofetil. Outcomes were measured in terms of remission of NS, adverse effects of drugs, and progression of disease. After 6 months of treatment, 16/23 (69.5%) patients on CSA achieved remission and 18/22 (81.8%) on TAC achieved remission (P = 0.3). The side effects hypertrichosis, and gum hyperplasia were significantly less in TAC group as compared to CSA group (P < 0.001). The 1-, 2-, 3-, 4-, and 5-year estimated renal survival (doubling of serum creatinine as event) in CSA group was 96%, 91%, 85%, 54%, and 33% and in TAC group was 96%, 95%, 90%, 89%, and 79%, respectively (P = 0.02). Although TAC and CSA are equally efficacious, TAC has significantly less side effects. The long-term outcome of renal function was significantly better in patients who were treated with TAC as compared to CSA.

Direct-acting Antiviral Agents in Hepatitis C Virus-infected Renal Allograft Recipients: Treatment and Outcome Experience from Single Center

Hepatitis C virus (HCV) infection in renal allograft recipient is associated with increased morbidity and mortality. At present, only few studies related to treatment and outcomes of HCV-infected renal allograft recipients with DAAs have been published. We aimed the study to assess the efficacy and safety of sofosbuvir-based regimens in HCV-infected renal allograft recipients. We analyzed data of 22 eligible HCV-infected renal allograft recipients (14 genotype-3, 6 genotype-1, one each genotype-2 and 4) who were treated with DAAs at our institute. DAA regimen included sofosbuvir and ribavirin with or without ledipasvir or daclatasvir for 12–24 weeks. Patients were followed up for 24 weeks after completion of treatment. A rapid viral response of 91%, end of therapy response of 100%, and sustained viral response at 12 and 24 weeks of 100% with rapid normalization of liver enzymes were observed. Therapy was well tolerated except for ribavirin-related anemia. A significant decrease in tacrolimus trough levels was observed and most patients required increase in tacrolimus dose during the study. Treatment with newer DAAs is effective and safe for the treatment of HCV-infected renal allograft recipients.