Abstract TP94: Optimizing The Utilization Of Cardiac Computed Tomography Angiography Among Patients With Ischemic Stroke

Background: The current AHA guidelines recommend (class IIb) advanced cardiac imaging in embolic stroke of unknown source (ESUS). We aim to better characterize the role of cardiac CTA (cCTA) in the evaluation of stroke patients.

Method: A retrospective review of stroke patients at a comprehensive stroke center, who had cCTA between 12/2016 and 11/2020 was conducted using institutional registries. Ischemic stroke patients with ESUS, cryptogenic (with ESUS as a competing etiology) and cardio-embolic etiologies were included. Only cardioembolic etiologies in which a suspicion of intracardiac thrombus with either a known diagnosis of atrial fibrillation or presence of LVAD were included. Cases with TIA, large vessel disease, small vessel disease, dissection or hemodynamic etiologies were excluded. TTE and cCTA results from all cases were reviewed for remarkable findings, most notably intracardiac thrombus, and analyzed if a change in anti-thrombotic therapy was directly attributable to cCTA results.

Results: As per our criteria, 96 cases (Female 42.7%, Black 37.5%, Age mean: 63.7 years) were included, of whom 45 (46.9%) were ESUS, 21 (21.9%) were cryptogenic, and 30 (31.2%) were cardioembolic. cCTA revealed intracardiac thrombus in 5 (5.2%) cases, all with LA thrombus. Of these, 3 (60%) had escalation of anti-thrombotic therapy. Interestingly, in one patient who had both cMRI and cCTA imaging, the cMRI revealed an apical LV thrombus which was not detected on cCTA.

Conclusion: In this retrospective analysis of 96 select stroke cases, escalation of anti-thrombotic therapy from anti-platelets to full dose anti-coagulation was indicated in 3 patients (3.1%) with addition of cCTA. Compared to a similar cohort of patients from the same institutional registry using cMRI as the advanced cardiac imaging modality, cCTA did not reveal any LV thrombi and even missed a case of LV thrombus seen on cMRI suggesting lower sensitivity for cCTA to detect LV thrombus. Further analysis of data is in process to determine the subset of stroke patients who would benefit the most from cCTA.

Abstract TP105: Optimizing The Utilization Of Cardiac Magnetic Resonance Imaging Among Patients With Ischemic Stroke

Background: The current AHA guidelines recommend (class IIb) advanced cardiac imaging in an embolic stroke of unknown source (ESUS). We aim to better characterize the role of cardiac MRI (cMRI) in the evaluation of stroke patients and determine patient characteristics that may increase the positive predictive value of cMRI.

Method: A retrospective review of stroke patients at a comprehensive stroke center, who had cMRI between 12/2016 and 11/2020 was conducted using institutional registries. Ischemic stroke patients with ESUS, cryptogenic (with ESUS as a competing etiology), and cardioembolic etiologies were included. Cases with TIA, large vessel, small vessel, or hemodynamic etiologies were excluded. Cardioembolic etiology was defined as newly diagnosed Afib patients with TTE abnormalities including wall motion abnormalities and/or reduced LVEF <50%, stroke while compliant with anticoagulation for known Afib, or among whom the timing of restarting anticoagulation was in question. TTE and cMRI results from all cases were reviewed for remarkable findings, most notably intracardiac thrombus, and analyzed if a change in anti-thrombotic therapy was directly attributable to cMRI results.

Results: As per our criteria, 250 cases (Female 44.4%, Black 29.6%, Age mean: 65.2 years) were included, of whom 146 (58.4%) were ESUS, 86 (34.4%) were cryptogenic, and 18 (7.2%) were cardioembolic. Sixteen (6.4%) revealed intracardiac thrombus, of which 10 had LV thrombus, 5 had LA thrombus, and 1 had RA thrombus along with questionable PFO on cMRI. Of these, 14 (87.5%) had an escalation of anti-thrombotic therapy. For the other 2 cases, despite cMRI obtained due to low LVEF and revealing LA thrombus, antithrombotic regimen was not changed. Eight (3.2%) additional patients were placed on anticoagulation secondary to incidental findings.

Conclusion: In this large retrospective analysis of 250 select stroke cases, escalation of anti-thrombotic therapy from anti-platelets to full dose anti-coagulation was indicated in 14 patients (5.6%) with addition of cMRI. Further analysis of data is in process to determine the subset of stroke patients who would benefit the most from cMRI.

Is de novo membranous nephropathy suggestive of alloimmunity in renal transplantation? A case report

BACKGROUND

Post-transplant nephrotic syndrome (PTNS) in a renal allograft carries a 48% to 77% risk of graft failure at 5 years if proteinuria persists. PTNS can be due to either recurrence of native renal disease or de novo glomerular disease. Its prognosis depends upon the underlying pathophysiology. We describe a case of post-transplant membranous nephropathy (MN) that developed 3 mo after kidney transplant. The patient was properly evaluated for pathophysiology, which helped in the management of the case.

CASE SUMMARY

This 22-year-old patient had chronic pyelonephritis. He received a living donor kidney, and human leukocyte antigen-DR (HLA-DR) mismatching was zero. PTNS was discovered at the follow-up visit 3 mo after the transplant. Graft histopathology was suggestive of MN. In the past antibody-mediated rejection (ABMR) might have been misinterpreted as de novo MN due to the lack of technologies available to make an accurate diagnosis. Some researchers have observed that HLA-DR is present on podocytes causing an anti-DR antibody deposition and development of de novo MN. They also reported poor prognosis in their series. Here, we excluded the secondary causes of MN. Immunohistochemistry was suggestive of IgG1 deposits that favoured the diagnosis of de novo MN. The patient responded well to an increase in the dose of tacrolimus and angiotensin converting enzyme inhibitor.

CONCLUSION

Exposure of hidden antigens on the podocytes in allografts may have led to subepithelial antibody deposition causing de novo MN.

Two Cases of Vasculitis with Renal Vein Thrombosis

We present a series of two cases of ANCA associated Vasculitis (AAV) presenting as Pulmonary Renal syndrome with associated renal vein thrombosis. Although there are enough evidences suggesting association of venous thrombosis with AAVs, the incidence of renal vein thrombosis is rare. Renal vein thrombosis should be ruled out in cases where there is delay in recovery of renal function in patients with AAV. Positive laboratory values for anti-Proteinase-3 (PR3) and anti-Myeloperoxidase (MPO) ANCA in the cases that presented as Rapidly Progressive Glomerulonephritis, helped in early initiation of treatment with complete recovery of Renal function.

The ability of spore formers to degrade milk proteins, fat, phospholipids, common stabilizers, and exopolysaccharides

Spore formers are common spoilage-causing microorganisms in dairy products; however, their modes of spoilage (proteolysis, lipolysis, etc.) have not been described in detail for cultured dairy products such as sour cream and yogurt. The objective of the present study was to test the ability of spore-forming strains isolated from dairy environments for their spoilage-causing activities at typical sour cream (24°C) and yogurt (42°C) fermentation temperatures. A total of 25 spore-forming strains were isolated from different sources, including raw milk, pasteurizer balance tank, biofilms formed on heat exchangers, and milk powder. These strains were tested for proteolytic and lipolytic activities and for their ability to degrade phospholipids, common stabilizers (starch, gelatin, xanthan gum, pectin), and exopolysaccharides (EPS) at sour cream and yogurt fermentation temperatures. A higher percentage of positive strains was observed for selected activities at yogurt fermentation temperature compared with sour cream fermentation temperature. Identified proteolytic spore-forming strains, based on a skim milk agar method, were subsequently quantified for their level of proteolysis using non-casein nitrogen (NCN) content and sodium dodecyl sulfate-PAGE (SDS-PAGE). The proteolytic strains that showed the highest levels of proteolysis (highest percentages of NCN content) at 24°C were Bacillus mojavensis BC, Bacillus cereus DBC, Bacillus subtilis DBC, B. mojavensis DBC1, and Paenibacillus polymyxa DBC1. At 42°C the strains with the highest levels of proteolysis (highest percentages of NCN content) were B. subtilis DBC, B. mojavensis BC, B. mojavensis DBC1, B. cereus DBC, and Bacillus licheniformis DBC6. Results of SDS-PAGE demonstrated that proteolytic strains had primarily hydrolyzed β- and κ-CN. A viscometric method was used to evaluate the susceptibility of exopolysaccharides (EPS) to degradation by selected spore formers. This method helped to determine that EPS produced by commercial yogurt and sour cream cultures is susceptible to degradation by spore formers present in dairy environments.

Influence of partially demineralized milk proteins on rheological properties and microstructure of acid gels

Innovative clean label processes employed in the manufacture of acid gels are targeted to modify the structure of proteins that contribute to rheological properties. In the present study, CO₂-treated milk protein concentrate powder with 80% protein in dry matter (TMPC80) was mixed with nonfat dry milk (NDM) in different ratios for the manufacture of acid gels. Dispersions of NDM and TMPC80 that provided 100, 90, 70, and 40% of protein from NDM were reconstituted to 4.0% (wt/wt) protein and 12.0% (wt/wt) total solids. Dispersions were adjusted to pH 6.5, followed by heat treatment at 90°C for 10 min. Glucono-δ-lactone was added and samples were incubated at 30°C, reaching pH 4.5 ± 0.05 after 4 h of incubation. Glucono-δ-lactone levels were adjusted to compensate for the lower buffering capacity of samples with higher proportions of TMPC80, which is attributable to the depletion of buffering minerals from both the serum and micellar phase during preparation of TMPC80. Sodium dodecyl sulfate-PAGE analysis indicated a higher amount of caseins in the supernatant of unheated suspensions with increasing proportions of CO₂-treated TMPC80, attributable to the partial disruption of casein micelles in TMPC80. Heat treatment reduced the level of whey proteins in the supernatant due to the heat-induced association of whey proteins with casein micelles, the extent of which was larger in samples containing more micellar casein (i.e., samples with a lower proportion of TMPC80). Particle size analysis showed only small differences between nonheated and heated dispersions. Gelation pH increased from ˜5.1 to ˜5.3, and the storage modulus of the gels at pH 4.5 increased from ˜300 to ˜420 Pa when the proportion of protein contributed by TMPC80 increased from 0 to 60%. Water-holding capacity also increased and gel porosity decreased with increasing proportion of protein contributed by TMPC80. The observed gel properties were in line with microstructural observations by confocal microscopy, wherein sample gels containing increasing levels of TMPC80 exhibited smaller, well-connected aggregates with uniform, homogeneous pore sizes. We concluded that TMPC80 can be used to partially replace NDM as a protein source to improve rheological and water-holding properties in acid gels. The resultant gels also exhibited decreased buffering, which can improve the productive capacity of yogurt manufacturing plants. Overall, the process can be leveraged to reduce the amount of hydrocolloids added to improve yogurt consistency and water-holding capacity, thus providing a path to meet consumer expectations of clean label products.

Montmorillonite-alginate composites as a drug delivery system: Intercalation and In vitro release of diclofenac sodium

Diclofenac sodium and alginate was intercalated into montmorillonite to form uniform sized beads by gelation method. The structure and surface morphology of the synthesized composite beads were characterized by powdered X-ray diffraction, Fourier transform infrared spectroscopy, thermo gravimetric analysis and scanning electron microscopy. Diclofenac release kinetics of the composite in simulated intestinal fluid medium (pH 7.4) and effect of montmorillonite content on the in vitro release of diclofenac from diclofenac-montmorillonite-alginate composites bead was investigated by UV/Vis spectrophotometer. Diclofenac encapsulation efficiency in the montmorillonite-alginate composites bead increases with an increase in the montmorillonite content. The control release of diclofenac from diclofenac-montmorillonite-alginate composites beads was observed to be better as compared to diclofenac-alginate beads.

A comparative study of loratadine versus pheniramine maleate in chronic idiopathic urticaria

Fifty cases with chronic idiopathic urticaria of more than 3 months duration were selected and divided into two groups. Group 'A' was given 10 mg loratadine once daily, while group 'B' was given pheniramine maleate 25 mg, twice daily for one month. All patients were followed for one month more. 48% excellent response was observed in group 'A' while 16% excellent response was observed in group 'B'. Good response was observed in 24% of patients in group 'A', while in group 'B' 16% of patients had good response. No side effects were observed in loratadine group, while drowsiness was observed in pheniramine group.

Identification of two GTP-binding proteins in the chloroplast protein import machinery

Two of four proteins that associated with translocation intermediates during protein import across the outer chloroplast envelope membrane were identified as guanosine triphosphate (GTP)-binding proteins. Both proteins are integral membrane proteins of the outer chloroplast membrane, and both are partially exposed on the chloroplast surface where they were accessible to thermolysin digestion. Engagement of the outer membrane's import machinery by an import substrate was inhibited by slowly hydrolyzable or non-hydrolyzable GTP analogs. Thus, these GTP-binding proteins may function in protein import into chloroplasts.

Hypothalamic noradrenergic pathways exert an influence on neuroendocrine and clinical status in experimental autoimmune encephalomyelitis

The immunomodulatory action of corticosteroids and the ability of central noradrenergic systems to activate the hypothalamic-pituitary-adrenal (HPA) axis led us to investigate the relationship between neuroendocrine status and the clinical course of encephalomyelitis (EAE) following adrenalectomy and depletion of noradrenaline (NA) centrally or peripherally. A significant inverse correlation was found between hypothalamic NA and serum corticosterone (CS) at peak clinical signs of EAE in all the sham groups or when NA was depleted only in the peripheral nervous system. A positive correlation was found between serum CS and disease severity, and in all experimental groups with intact peripheral and/or central noradrenergic pathways a uniformly increased splenic NA content was also observed at peak disease. Administration of 6-OHDA i.p. to neonatal or adult Lewis rats produced a significant depletion of splenic NA alone which resulted in increased disease severity, despite the fact that circulating CS was elevated. Thus the rise in the NA content of lymphoid tissue at peak clinical signs contributes to recovery. A single i.c.v. injection of 6-OHDA into the hypothalamic region resulted in an 80% reduction in NA content, which subsequently modified the clinical severity of EAE. Serum CS levels rose preclinically in the treated group and remained high despite milder clinical disease than that seen in the sham group. The overriding immunoregulatory influence of glucocorticoids is demonstrated by the rapid onset of clinical EAE and morbidity in adrenalectomized animals. However, the strong inverse correlation found between hypothalamic NA and circulating CS indicates that regulation of the HPA axis may ultimately be controlled by central sympathetic pathways.

Histopathology of multiple sclerosis lesions detected by magnetic resonance imaging in unfixed postmortem central nervous system tissue

Postmortem unfixed whole brains from 17 multiple sclerosis and 6 control cases were examined by magnetic resonance imaging (MRI) using a T2-weighted spin echo sequence and histology to determine the relationship between areas of abnormal MRI signal and underlying pathological change. In group 1, small MRI lesions and correspondingly small plaques, most of which were chronic, were detected histologically in 5 brains. In 4 brains there were more extensive areas of both abnormal signal and histological plaques which were more often active (group 2). However, in a further 5 brains extensive MRI abnormalities were observed when only small periventricular plaques were present histologically (group 3). Lesions in the hindbrain and cerebral grey matter were infrequently observed by MRI. The extensive MRI abnormalities seen in areas in which only small histological plaques were found may be the result of vascular permeability changes in the normal-appearing white matter surrounding plaques.

Splenic noradrenergic and adrenocortical responses during the preclinical and clinical stages of adoptively transferred experimental autoimmune encephalomyelitis (EAE)

When experimental autoimmune encephalomyelitis (EAE) is induced by adoptive transfer of myelin basic protein (MBP)-specific lymphocytes the splenic noradrenergic and adrenocortical responses mirror in most respects those that occur following sensitization with spinal cord and Freund's adjuvant (CFA), despite the absence of the primary immune challenge. An early drop in splenic noradrenaline (NA), observed only when purified protein derivative-primed cells are transferred may reflect a vigorous proliferative response in vitro, not observed with MBP-specific cells. However, serum corticosterone (CS) levels and the density of splenocyte beta-adrenergic receptors were increased in both experimental groups within 3 days of cell inoculation. The stress of clinical signs of EAE resulted in highly significant increases in both splenic NA and plasma CS. Thus adoptively transferred EAE provides a well-delineated model of autoimmune disease for investigating the immunomodulatory role of the neural and endocrine systems.

Autotransplantation of premolar teeth to replace missing maxillary central incisors

Orthodontic treatment decisions when maxillary central incisors are absent or are of poor prognosis, are discussed. Autotransplantation of mandibular first premolars to the incisor region is suggested as an approach in selected cases. The literature is reviewed, surgical technique described and case selection summarized. Cases are reported where autotransplantation of premolars to the maxillary incisor region has produced good functional and aesthetic results.