Assessing sleep-related breathing disorders among newly diagnosed rheumatoid and psoriatic arthritis patients: a cross-sectional study

OBJECTIVES

This cross-sectional study aimed to determine the prevalence and risk factors for sleep-related breathing disorders (SRBD) in newly diagnosed, untreated rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients, and to develop a screening algorithm for early detection.

METHODS

We evaluated newly diagnosed RA or PsA patients using the Epworth Sleepiness Scale (ESS) questionnaire, cardiorespiratory polygraphy (RPG), and clinical and laboratory assessments. Sleep apnea syndrome (SAS) was diagnosed based on pathological RPG findings excessive daytime sleepiness, defined as ESS score above 10.

RESULTS

The study included 39 patients (22 RA, 17 PsA) and 23 controls. In RPG, SRBD was identified in 38.5% of arthritis patients compared to 39.1% of controls (p = 1.00), with male gender (p = .004) and age (p < .001) identified as risk factors. Excessive daytime sleepiness was noted in 36.4% of RA patients, 17.6% of PsA patients, and 21.7% of controls. Of the 24 patients diagnosed with SRBD, 41.6% met the criteria for SAS. SAS prevalence was 31.8% among RA patients, 0% in PsA patients, and 13% in controls. A significant association was observed between excessive daytime sleepiness and SRBD (p = .036).

CONCLUSION

Our findings reveal a high prevalence of SRBD in newly diagnosed, untreated RA and PsA patients in ESS and RPG, with excessive daytime sleepiness being a reliable predictor of SRBD. Patients with RA exhibited a higher predisposition to SAS. We therefore suggest incorporating ESS and RPG as screening tools in RA or PsA for early detection and management of SRBD.

Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders

To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.

[Allergic bronchopullmonary aspergillosis (ABPA) - an Update]

Allergic bronchopulmonary aspergillosis (ABPA) is a regular occurrence in everyday pneumology. ABPA should be considered in patients with severe asthma, in mould allergic patients with very high serum IgE levels and in patients with cystic fibrosis. The aim should be to make the diagnosis as early as possible in the course of the disease to avoid late complications such as bronchiectasis and fibrotic lung remodelling. Symptoms are highly variable and rather non-specific, overlapping with those of the underlying primary disease. However, clearly defined diagnostic criteria exist, so that the diagnosis can be made relatively easily if one thinks of it. In therapy, systemic steroids and antifungals (mainly azoles) play the leading role. However, biologics have been gaining in importance in recent years, especially in cases of insufficient therapy response or occurrence of side effects to standard therapies, as well as an alternative in permanently steroid-dependent patients.

The CT derived angle between the transseptal puncture site and the left atrial appendage as a predictor for complex interventional occlusion procedures

OBJECTIVE

To evaluate the role of the CT-derived angle between the intra-atrial septum (IAS) and the left atrial appendage (LAA) on procedural complexity and clinical outcomes in left atrial appendage occlusion (LAAO) procedures.

BACKGROUND

Given the broad variations in anatomy, LAAO remains one of the most challenging interventional procedures in structural heart disease. In recent years, preprocedural cardiac tomography (CT) has evolved as a valuable tool; however, prediction of procedural complexity remains cumbersome.

METHODS

We retrospectively analyzed 47 patients that underwent LAAO at our center in whom pre-procedural cardiac CT-scans were available. Among other baseline parameters, we measured the angle between the LAA ostium and the preferred transseptal puncture site at the IAS. We compared patients with an angle above and below the median regarding procedural characteristics and procedural outcome.

RESULTS

The median angle between the LAA and the IAS was 127.3° (IQR: 120.9-141.3). LAAO took longer in patients with a measured angle below the median (55.0 ± 22.7 min vs. 41.3 ± 17.5 min; p = .04), resulting in longer radiation times (13.0 ± 5.3 min vs. 9.8 ± 5.7 min; p = .04) and more contrast use (61.1 ± 47.5 mL vs. 33.6 ± 24.7 mL; p = .05). Moreover, the necessity for a sheath exchange was significantly higher (30.4% vs. 4.2%, p = .02) and device repositioning or device resizing trended to be more frequent (26.1% vs. 8.3%; p = .1 and 21.7% vs. 8.3%; p = .2). There were no differences in procedural outcome, device-position and peri-device leak (PDL).

CONCLUSIONS

The angle between the transseptal puncture site and the LAA ostium may serve as a predictor for more demanding LAAO interventions. In our study a steeper angle led to a prolonged procedure resulting in higher doses of contrast and radiation, but was not associated with a worse procedural outcome.

Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve repair

AIMS

The role of right ventricular function in patients undergoing transcatheter tricuspid valve repair (TTVR) is poorly understood. This study investigated the association of right ventricular ejection fraction (RVEF) assessed by cardiac computed tomography (CCT) with clinical outcomes in patients undergoing TTVR.

METHODS AND RESULTS

We retrospectively assessed three-dimensional (3D) RVEF by using pre-procedural CCT images in patients undergoing TTVR. RV dysfunction was defined as a CT-RVEF of <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within 1 year after TTVR. Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Procedural success and in-hospital mortality were comparable between patients with CT-RVEF <45% and ≥45%. However, CT-RVEF of <45% was associated with a higher risk of the composite outcome (hazard ratio: 2.99; 95% confidence interval: 1.65-5.41; P = 0.001), which had an additional value beyond two-dimensional echocardiographic assessments of RV function to stratify the risk of the composite outcome. In addition, patients with CT-RVEF ≥45% exhibited the association of procedural success (i.e. residual tricuspid regurgitation of ≤2+ at discharge) with a decreased risk of the composite outcome, while this association was attenuated in those with CT-RVEF <45% (P for interaction = 0.035).

CONCLUSION

CT-RVEF is associated with the risk of the composite outcome after TTVR, and a reduced CT-RVEF might attenuate the prognostic benefit of TR reduction. The assessment of 3D-RVEF by using CCT may refine the patient selection for TTVR.

[CT technology: photon-counting detector computed tomography]

BACKGROUND

Photon-counting detector computed tomography (PCD-CT) is a CT technology that overcomes many limitations of conventional detectors. Direct conversion of photons hitting the detector into electrical signals combined with more sensitive and accurate photon detection simultaneously allows spectral evaluation and also potential reduction in radiation exposure to the patient. The combination of energy thresholds and elimination of detector septa allows for a reduction of electronic noise, an increase of spatial resolution, and an improvement of dose efficiency.

ACHIEVEMENTS

Recent research has confirmed significantly reduced image noise, reduced radiation dose, increased spatial resolution, improved iodine signal, and a reduction in artifacts. Spectral imaging potentiates these effects and also allows retrospective calculation of virtual monoenergetic images, virtual noncontrast images or iodine maps. Thus, the photon-counting technique offers the possibility of using various contrast agents, with the prospect of single-scan multiphase imaging or visualization of specific metabolic processes. Therefore, further research and complementary approval processes are necessary for clinical application. Likewise, further research is needed to develop and validate optimal settings and reconstructions for a wide variety of situations, as well as to test new application possibilities.

CONCLUSIONS

The only photon-counting detector CT device available on the market to date received clinical approval in 2021. It remains to be seen which other applications will become possible through improvements in hardware and software. This technology has already demonstrated an impressive superiority compared with the current standard of CT imaging, especially regarding high-resolution imaging of detailed structures and examinations with high radiation exposure.

[Radiological embolization procedures in acute gastrointestinal, peritoneal and muscular hemorrhage]

BACKGROUND

Treatment of acute hemorrhage is particularly challenging due to its sudden onset and the fact that it is often life-threatening. Potential causes include bleeding ulcerations of the gastrointestinal tract or tumor bleeding, but acute bleeding can also occur spontaneously or be traumatic, iatrogenic, or inflammatory.

OBJECTIVE

To demonstrate the basic principles of catheter embolization, as well as various embolic materials and their properties.

RESULTS

Today there are a wide range of embolization materials available. Ultimately the duration and extent of the desired occlusion are decisive when selecting an embolic material. Mechanical occlusion devices, particulates, and liquid embolic agents are available.

CONCLUSION

Irrespective of the wide range of different etiologies, radiological embolization therapy is a very safe treatment option in cases of computed tomographic evidence of active hemorrhage. Ultimately, the interventionalist's comprehensive knowledge of the relevant characteristics is crucial for the success of therapy.

Transfemoral recanalization of occluded TIPS

Purpose

To report the safety and efficacy of percutaneous transfemoral venous recanalization of occluded intrahepatic portosystemic stents (TIPS) in cases where the transjugular approach is not feasible.

Materials and Methods

Between 2000 and 2020, 8 patients with occluded TIPS underwent recanalization via a percutaneous transfemoral venous access. Prior recanalization via a typical transjugular approach was attempted in all cases. Primary technical success was defined as successful crossing of the occlusion. Secondary technical success was defined as the rate of successful TIPS recanalization. Periprocedural complications were evaluated to assess procedural safety.

Results

In 8/8 patients transfemoral venous TIPS recanalization was successful. No procedure-related complications were observed.

Conclusions

The transfemoral venous approach is a safe and efficient alternative for TIPS recanalization in cases where the transjugular approach is not feasible.

Cranial stent position is independently associated with the development of TIPS dysfunction

Complications of portal hypertension can be treated with transjugular intrahepatic portosystemic shunt (TIPS) in selected patients. TIPS dysfunction is a relevant clinical problem. This study investigated the prognostic value of two-dimensional (2D) TIPS geometry for the development of TIPS dysfunction. Three hundred and seven patients undergoing TIPS procedure between 2014 and 2019 were analyzed in this monocentric retrospective study. 2D angiograms from the patients with and without TIPS dysfunction were reviewed to determine geometric characteristics including insertion and curve angles and the location of the stent. Primary outcome was the development of TIPS dysfunction. A total of 70 patients developed TIPS dysfunction and were compared to the dysfunction-free (n = 237) patients. The position of the cranial stent end in the hepatic vein and the persistence of spontaneous portosystemic shunts were significantly associated with the development of TIPS dysfunction. Among significant parameters in univariable regression analysis (portal vein-pressure after TIPS, Child-Pugh Score before TIPS, MELD before TIPS and white blood cell count before TIPS), multivariable models showed cranial stent position (p = 0.027, HR 2.300, 95% CI 1.101-4.806) and SPSS embolization (p = 0.006, HR 0.319, 95% CI 0.140-0.725) as the only predictors of TIPS dysfunction. This monocentric study demonstrates that the position of the cranial stent end is independently associated with the development of TIPS dysfunction. The distance of the cranial stent end to the IVC at the time of TIPS placement should be less than 1 cm in 2D angiography.

Baseline PA/BSA ratio in patients undergoing transcatheter aortic valve replacement - A novel CT-based marker for the prediction of pulmonary hypertension and outcome

BACKGROUND

Pulmonary hypertension (pH) has a prognostic impact on patients undergoing transcatheter aortic valve replacement (TAVR). Pulmonary artery (PA) dilatation assessed by multidetector computed tomography (MDCT) has the potential to predict PH. The aim of the study was to evaluate the clinical parameters associated with PA dilatation and to investigate its prognostic relevance in patients undergoing TAVR.

METHODS

In 770 patients undergoing TAVR between February 2016 and July 2019, PA diameter was measured by MDCT before TAVR. Additionally, PA diameter divided by ascending aorta diameter or body surface area (BSA) was calculated.

RESULTS

Of all the CT-derived parameters compared with a receiver operating characteristic curve, the value for PA/BSA with a median of 1.68 (IQR 1.47, 1.91) cm/m2 showed the greatest area-under-the-curve (0.75) for predicting PH at baseline. Based on this median, patients were assigned to a small PA/BSA (n = 386) or a large PA/BSA (n = 384) group. Hereby, a large PA/BSA was independently associated with PH at baseline (OR:8.39 [5.36-13.14], p < 0.001) and after TAVR (OR:1.73 [1.18-2.53], p = 0.005). A large PA/BSA was associated with a significantly higher cumulative two-year all-cause mortality compared to small PA/BSA (30.0% vs. 13.7%, p < 0.001), which was supported in the multivariable model (HR:1.87; 95%CI, 1.12-3.04; p = 0.017).

CONCLUSION

Patients with a large PA/BSA on MDCT are more likely to have PH at baseline and after TAVR. Large PA/BSA is associated with an increased risk of mortality and could provide additional information for risk stratification in patients undergoing TAVR.

Comparison of Aspiration Catheters with Modified Standard Catheters for Treatment of Large Pulmonary Embolism Using an In-vitro Patho-Physiological Model

PURPOSE

The presented in-vitro study provides a comparison of various catheters for mechanical treatment of large-burden pulmonary embolism (PE) under standardized conditions, using a new test rig. Dedicated aspiration catheters (JETi®, Penumbra Indigo®, Aspirex®) were compared with standard catheters (Pigtail, Multi-Purpose, Balloon Catheter) applied for embolus fragmentation.

MATERIALS AND METHODS

Emboli prepared from porcine blood were washed into the test rig which consists of anatomical models of the pulmonary artery (PA) and of the right heart in combination with a pulsatile drive system. For all catheters, the duration of the recanalization procedure and the weight percentage (wt%) of the remaining, removed and washed-down clot fractions were evaluated. For aspiration catheters, the aspirated volume was measured.

RESULTS

All catheters achieved full or partial recanalization. The aspiration catheters showed a significantly (p < 0.05) lower procedure time (3:15 min ± 4:26 min) than the standard fragmentation catheters (7:19 min ± 4:40 min). The amount of thrombus removed by aspiration was significantly (p < 0.001) higher than that by fragmentation, averaging 86.1 wt% ± 15.6 wt% and 31.7 wt% ± 3.8 wt%, respectively. Nonetheless, most of the residue was fragmented into pieces of ≥ 1 mm and washed down. Only in 2 of 36 tests, a residual thrombus of 11.9 wt% ± 5.1 wt% remained in the central PA.

CONCLUSION

Comparison under standardized in-vitro patho-physiological conditions showed that embolus fragmentation with standard catheters is clearly inferior to aspiration with dedicated catheters in the treatment of large-burden PE, but can still achieve considerable success.

LEVEL OF EVIDENCE

No level of evidence, experimental study.

Impact of prior smoking exposure and COPD comorbidity on treatment response to monoclonal antibodies in patients with severe asthma

Despite the prognostic role of smoking in asthma [1], clinical studies of asthma usually exclude current smokers or ex-smokers with a smoking history of >10 pack-years [2–5]. Specifically, the role of humanised monoclonal antibody therapy in patients with severe asthma and prior smoking exposure has not been studied; however, these drugs are used in patients with severe asthma and a history of smoking [6–9]. The aim of the present study was to evaluate in a real-world setting how a history of smoking and comorbid COPD affect the clinical outcome of patients suffering from severe asthma that are treated with monoclonal antibodies.

Patients suffering from severe asthma may benefit from an antibody treatment irrespective of their status as an ex-smokerhttps://bit.ly/3fYC8tC

Pseudoaneurysm associated haemosuccus pancreaticus - a rare and dangerous disease

Background

In patients with upper gastrointestinal bleeding and hemorrhage originating from the major duodenal papilla pseudoaneurysm associated haemosuccus pancreaticus (HP) is a rare differential diagnosis which should be considered. Diagnosis may be challenging, as clinical presentation is often unspecific with only intermittent hemorrhage. Treatment of the causal pseudoaneurysm is mandatory and endovascular coil embolization is the suitable first-line management strategy.

Until now there are only a very few studies about this clinical picture and its therapeutic options, especially data regarding whether additional fluid embolization is beneficial/necessary in HP is currently lacking.

Case presentation

We report a case of a 59-year-old male patient with chronic pancreatitis and haemosuccus pancreaticus caused by a pancreatico-arterial fistula with an associated inflammatory pseudoaneurysm of the splenic artery. Initially we sought to embolize the pseudoaneurysm with microcoils. As only one coil could be safely deployed in the pseudoaneurysm we additionally employed tissue adhesive embolization in order to achieve complete occlusion of the pseudoaneurysm as well as the pancretico-arterial fistula. In the presented case inflammatory levels decreased following embolization, possibly linked to a decline in pathologic excretion of elastase and autodigestion. As not only the pseudoaneurysm but also the underlying fistula were occluded, the risk of recurrence may conceivably be reduced.

Conclusions

Diagnosis of HP is difficult and treatment of the causal pseudoaneurysm is mandatory. Endovascular embolization is the suitable first-line management strategy, complete occlusion of the fistula should be considered when possible.

Nuclear medicine in SARS-CoV-2 pandemia: 18F-FDG-PET/CT to visualize COVID-19

The current outbreak of coronavirus SARS-CoV-2 has reached multiple countries worldwide. While the number of newly diagnosed cases and fatalities is rising quickly, far-reaching measures were enacted to prevent further spread. Diagnosis relies on clinical presentation, exposure history, PCR using specimens from the respiratory tract together with computed tomography (CT) imaging. One of the hallmarks of a critical course of COVID-19 is the development of severe acute respiratory distress syndrome (ARDS). As management of COVID-19 can be considered a multi-disciplinary approach involving various medical specialties, we here review the first ¹⁸F-FDG-PET/CT scans of COVID-19 to discuss how Nuclear Medicine could contribute to management of this disease.