Exploring the latest advances in 18F-FDG PET/CT and cardiac magnetic resonance for imaging for cardiac sarcoidosis diagnosis

Sarcoidosis is a systemic inflammatory disease that affects multiple organs. Various clinical signs are associated with cardiac sarcoidosis (CS), and the diagnosis process is complicated because any organ could be involved. Despite the critical clinical importance of early and precise diagnosis of CS, there is currently no gold-standard method for CS evaluation. The non-invasive imaging modalities of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and cardiac magnetic resonance (CMR) imaging have demonstrated the potential for identifying various histological characteristics of CS. Recently, the development of hybrid FDG-PET/CMR scanners has enabled the simultaneous acquisition of these attributes. Compared to just one imaging modality, these scanners detect CS and stratify risk more accurately and with higher sensitivity. Analyzing the potential role of concurrent FDG-PET/CMR in enhancing the diagnosis of CS, the present review concentrates on the advantages of this technique in light of recent technological developments.

Evaluating the use of antiviral drugs in HIV patients with cardiovascular diseases and how to reduce the incidence of cardiac events in these patients

Globally, the incidence of newly diagnosed human immunodeficiency virus (HIV) infections is concerning. Despite enhancing the quality of life for this patient population, antiretroviral therapy (ART) is linked to an increased risk of cardiovascular disease (CVD). In people living with HIV (PLWH) undergoing ART, recent research has demonstrated that the use of statins and aspirin (ASA) can reduce the incidence or progression of CVD. However, research has demonstrated that interactions may occur when these medications are used concurrently in the treatment regimen of PLWH. Therefore, we conclude this systematic review to evaluate the use of ART in HIV individuals with CVD and also the effect of adding ASA and statins to ART for reducing the cardiac adverse events.

The role of 18F-fluorodeoxyglucose PET/computed tomography in the diagnosis and monitoring of large vessel vasculitides - a review article

In the last two decades, advancements in positron emission tomography (PET) technology have increased the diagnostic accuracy of patients with large-vessel vasculitis (LVV). Numerous systematic reviews and meta-analyses have been conducted, and patients suspected of having LVV can be diagnosed earlier with 18F-FDG PET. Two subtypes, giant cell arteritis (GCA) and Takayasu arteritis (TA), will progress when their response to corticosteroids and enhanced immunosuppression is inadequate. In the majority of patients, disease activity cannot be monitored solely through laboratory procedures; consequently, glucose metabolism may be a source of potential biomarkers. In this article, we discuss the current state of 18F-FDG PET/CT imaging standards.

Admission NT-proBNP and outcomes in patients without history of heart failure hospitalized with COVID-19

Aims

We examined the value of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in patients admitted for coronavirus disease 2019 (COVID‐19) without prior history of heart failure (HF) or cardiomyopathy.

Methods and results

Retrospective cohort of consecutive adults (N = 679; median age 59 years; 38.7% women; 87.5% White; 7.1% Black; 5.4% Asian; 34.3% Hispanic) admitted with documented COVID‐19 in an academic centre in Long Island, NY. Admission NT‐proBNP was categorized using the European Society of Cardiology Heart Failure Association age‐specific criteria for acute presentations. We examined (i) mortality and the composite of death or mechanical ventilation and (ii) out‐of‐hospital, intensive care unit (ICU)‐free, and ventilator‐free days at 28 days. Estimates were adjusted for confounders using a lasso selection process. Using age‐specific criteria, 417 patients (61.4%) had low, 141 (20.8%) borderline, and 121 (17.8%) high NT‐proBNP. Mortality was 5.8%, 20.6%, and 36.4% for patients with low, borderline, and high NT‐proBNP, respectively. In lasso‐adjusted models, high NT‐proBNP was associated with higher mortality [hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.06–4.39; P = 0.034] and composite endpoint rates (HR 1.66; 95%CI 1.04–2.66; P = 0.035). Patients with high NT‐proBNP had 32%, 33%, and 33% fewer out‐of‐hospital, ICU‐free, and ventilator‐free days compared with low NT‐proBNP counterparts. Results were consistent across age, sex, and race, and regardless of coronary artery disease or hypertension, except for stronger mortality signal with high NT‐proBNP in women.

Conclusions

In patients with COVID‐19 and no HF history, high admission NT‐proBNP is associated with higher mortality and healthcare resources utilization. Preventive strategies may be required for these patients.

High-dose methylprednisolone in nonintubated patients with severe COVID-19 pneumonia

BACKGROUND

Recent trials with dexamethasone and hydrocortisone have demonstrated benefit in patients with coronavirus disease 2019 (COVID-19). Data on methylprednisolone are limited.

METHODS

Retrospective cohort of consecutive adults with severe COVID-19 pneumonia on high-flow oxygen (FiO₂  ≥ 50%) admitted to an academic centre in New York, from 1 March to 15 April 2020. We used inverse probability of treatment weights to estimate the effect of methylprednisolone on clinical outcomes and intensive care resource utilization.

RESULTS

Of 447 patients, 153 (34.2%) received methylprednisolone and 294 (65.8%) received no corticosteroids. At 28 days, 102 patients (22.8%) had died and 115 (25.7%) received mechanical ventilation. In weighted analyses, risk for death or mechanical ventilation was 37% lower with methylprednisolone (hazard ratio 0.63; 95% CI 0.47-0.86; P = .003), driven by less frequent mechanical ventilation (subhazard ratio 0.56; 95% CI 0.40-0.79; P = .001); mortality did not differ between groups. The methylprednisolone group had 2.8 more ventilator-free days (95% CI 0.5-5.1; P = .017) and 2.6 more intensive care-free days (95% CI 0.2-4.9; P = .033) during the first 28 days. Complication rates were not higher with methylprednisolone.

CONCLUSIONS

In nonintubated patients with severe COVID-19 pneumonia, methylprednisolone was associated with reduced need for mechanical ventilation and less-intensive care resource utilization without excess complications.

76. Effect of Early Administration of Systemic Corticosteroids on Outcomes in Patients with COVID-19 Pneumonia

Background

Systemic corticosteroids (steroids) have been empirically used in acute respiratory distress syndrome, an entity also present in coronavirus disease 19 (COVID-19). Early steroids administration could accelerate resolution of symptoms and reduce intensive care unit (ICU) stay in these patients, but practice varies widely as evidence is scant.

Methods

We reviewed the records of 498 adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with COVID-19 requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 >50%, or high-flow nasal cannula). We excluded those (N=29) who received mechanical ventilation (MV) or died within 24h of admission. We followed patients until death or discharge. We compared outcomes between patients who received early steroids (i.e. prior to MV) and those who did not. We used adjusted Cox models to evaluate the composite of death or need for MV. We also evaluated healthcare resources utilization.

Results

Of 469 patients, 175 (37.3%) received steroids while on high flow O2. Table 1 summarizes the baseline characteristics. Patients who received steroids were more likely to have asthma, had slightly longer duration of symptoms, lower O2 saturation, higher NT-proBNP and lower IL-6 levels at baseline. In total, 228 patients (48.6%) reached the composite endpoint (123 died and 105 received MV). By 7 days, 32.5% of patients who received steroids died or were intubated vs. 44.8% of those who did not (log-rank P=0.008), Figure 1. In models adjusted for race, age, sex, comorbidities, baseline O2 saturation and procalcitonin, steroids reduced risk for death or MV by 44% (hazard ratio [HR] 0.56; 95%CI 0.42–0.76; P< 0.001). The effect was time-dependent with initial HR 0.34 (95%CI 0.21–0.56; P< 0.001) and daily attenuation by 10.2% (95%CI 1.7%–19.4%; P=0.017). Mortality at 7 and 14 days did not differ between groups (8.1% vs. 8.3% and 19.1% vs. 21.0%, respectively, log-rank P=0.75). Among discharged patients, length of hospital stay was longer, but ICU stay was shorter with steroids, Table 2.

Patient Characteristics According to Use of Early Steroids

Healthcare Resources Utilization According to Use of Early Steroids Among Discharged Patients

Conclusion

Early administration of steroids reduced primarily the need for MV in our high-risk COVID-19 patients, with shorter ICU utilization, at the expense of longer hospital stay. Further studies are needed to optimize the use of steroids in these patients.

Disclosures

All Authors: No reported disclosures

382. Incidence of Hospital-Acquired and Ventilator-Associated Pneumonia in Patients with Severe COVID 19 on High Flow Oxygen

Background

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) can be serious complications of coronavirus disease 19 (COVID-19). Co-infections may worsen outcomes and prolong hospitalization. This risk may be exacerbated by systemic corticosteroids (steroids) and other adjunctive therapies.

Methods

We reviewed the records of all adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with severe COVID-19 pneumonia, requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 &gt;50%, or high-flow nasal cannula). We excluded patients who received mechanical ventilation (MV) or died within 24h. Patients were followed until death or hospital discharge. We reviewed positive sputum cultures (PSC) for pathogenic microorganisms and calculated the incidence of HAP and VAP (nosocomial pneumonia, [NP]), rates of MV and impact on mortality. Fungi isolated from sputum, were considered colonization unless associated with fungemia. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on HAP or VAP.

Results

A total of 469 patients were included (Table 1). Of these, 199 (42.4%) required intensive care and 172 (36.7%) MV. Median length of stay was 13 days (8–22) and 105 (22.4%) had PSC. Of these, 59 were considered true pathogens (HAP: 11, VAP: 48), with predominance of S. aureus (MSSA) 38.9%, Enterobacteriaceae 33.8% and Pseudomonas species 18.6%. 39 isolates were considered colonization (Table 2); Patients with PSC &lt; 48h (N=7) from admission, were not considered NP. The incidence of NP was 7.0 per 1000 patient-days (95%CI 5.5–8.5). Of 11 patients with HAP, 9 needed MV. NP was more frequent among patients receiving steroids (9.0 vs 5.7 per 1000 patient-days; P=0.023). Use of tocilizumab was not associated with NP (6.2 vs 8.4 per 1000 patient-days; P=0.11). Mortality was nonsignificantly higher in patients with (20/59, 33.9%) vs. without (103/410, 25.1%) NP (P=0.16). Intubation and length of stay were the strongest predictors of NP in multivariable models.

Cohort Characteristics of Patients with Severe COVID -19 Pneumonia on High Flow Oxygen (N= 469)

Conclusion

Among high risk COVID-19 patients, NP is a common complication. MSSA and Enterobacteriaceae were the most frequent isolates. The risk increases with intubation, longer hospital stay and use of steroids but not tocilizumab.

Disclosures

All Authors: No reported disclosures

53. Incidence of Bloodstream Infections and Outcomes in Patients with Severe COVID-19 Pneumonia

Background

Coronavirus disease 19 (COVID-19) leading to acute respiratory distress syndrome is associated with need for intensive care (IC), mechanical ventilation (MV), and prolonged recovery. These patients are thus predisposed to blood stream infections which can worsen outcomes. This risk may be aggravated by adjunctive therapies.

Methods

We reviewed the medical records of all adults admitted to Stony Brook University Hospital, NY, from March 1 to April 15, 2020 with severe COVID-19 pneumonia (requiring high-flow O2). Patients who received MV or died within 24h were excluded. Patients were followed until death or hospital discharge. We reviewed positive blood cultures (PBC) for pathogenic microorganisms, and calculated the incidence of bacteremia, rates of infective endocarditis (IE), and impact on mortality. Microbes isolated only once and belonging to groups defined as commensal skin microbiota were labelled as contaminants. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on bacteremia.

Results

A total of 469 patients with severe COVID-19 pneumonia were included (Table 1). Of these, 199 (42.4%) required IC and 172 (36.7%) MV. Median length of stay was 13 days (8–22) and 94 (20.0%) had PBC. Of these, 43 were considered true pathogens (bacteremia), with predominance of E. faecalis and S. epidermidis, and 51 were considered contaminants (Table 2). The incidence of bacteremia (43/469, 9.2%) was 5.1 per 1000 patient-days (95%CI 3.8–6.4). An echocardiogram was performed in 21 patients, 1 had an aortic valve vegetation (IE) by methicillin sensitive S. aureus. Bacteremia rates were nonsignificantly higher with steroids (5.9 vs 3.7 per 1000 patient-days; P=0.057). Use of tocilizumab was not associated with bacteremia (5.8 vs 4.8 per 1000 patient-days; P=0.28). Mortality was nonsignificantly higher in patients with (15/43, 34.9%) vs. without (108/426, 25.4%) bacteremia (P=0.20). Length of stay was the strongest predictor of bacteremia, with risk increasing by 7% (95%CI 6%-9%, P&lt; 0.001) per additional day.

Cohort Characteristics of Patients with Severe COVID-19 Pneumonia on High-Flow O2 (N= 469)

Conclusion

The incidence of bacteremia was relatively low and IE was uncommon in this study of severe COVID-19 patients. Risk of bacteremia increased with longer hospital stay and with steroids use, but not with tocilizumab.

Disclosures

All Authors: No reported disclosures

Precipitating Factors and Treatment Outcomes of Hepatic Encephalopathy in Liver Cirrhosis

Background

Hepatic encephalopathy (HE) is a common cause of hospital admission in patients with liver cirrhosis (LC). The aims of this study were to evaluate the precipitant factors and analyze the treatment outcomes of HE in LC.

Methods

All the LC patients admitted between February 2017 and January 2018 for overt HE were analyzed for precipitating factors and treatment outcomes. Treatments were compared among three treatment groups: receiving lactulose, lactulose plus L-ornithine L-aspartate (LOLA), and lactulose plus rifaximin. The primary endpoints were mortality and hospital stay. The chi-square test was used to compare the different treatment outcomes with hospital stay and mortality with significance at p<0.05.

Results

A total of 132 patients (mean age 49.2 ± 10.2 years; male/female ratio of 103:29) were studied. The most common precipitating factor of HE was infection 65 (49.2%), followed by electrolyte imbalance 54 (41%), constipation 44 (33.33%), and gastrointestinal bleeding 21 (16%) patients. At the time of admission, 29 (22%), 76 (57.5%), 21 (16%), and six (4.5%) patients had grade I, II, III, and IV HE, respectively. The difference in mortality was not statistically significant (p=0.269) in three groups but the hospital stay was shorter among patients in groups B and C than in group A alone (7.36 ± 4.58 and 7 ± 3.69, 9.64 ± 5.28 days, respectively, p=0.015).

Conclusions

Infection, especially spontaneous bacterial peritonitis, was the commonest precipitating factor of HE. The combination of lactulose either with LOLA or rifaximin is equally effective in improving HE and reducing the duration of hospital stay than lactulose alone.

Recurrence of Multiple Gastrointestinal Angioectasias Despite Treatment with Argon Plasma Coagulation Requiring Thalidomide Treatment in a Patient with Cirrhosis: A Rare Case Report

Gastrointestinal (GI) angioectasia is an important cause of acute GI bleed, particularly in the elderly; however, GI angioectasia is an uncommon cause of upper GI bleeding related to cirrhosis. With the increasing incidence of liver cirrhosis and recent improvements in the treatment of advanced cirrhosis, this condition may become more common and should be considered a differential diagnosis in patients with cirrhosis who present with occult or overt GI blood loss.

We present the case of a 66-year-old man with liver cirrhosis admitted with acute upper GI bleeding that was found to have antral and duodenal angioectasia during esophagogastroduodenoscopy (EDG). Argon plasma coagulation (APC), which is considered the gold standard treatment for angioectasias was performed for hemostasis but was not successful in our case.

The next option was a combination of estrogen and progesterone, which was refused by the patient. Finally, thalidomide was administered and the patient responded to the medication, which was evident by the resolution of angioectasia during a repeat endoscopy done six months after treatment.

Variation in body mass index in patients with chronic obstructive pulmonary disease

Introduction:

Materials and Methods:

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Vector ecology and susceptibility in a malaria-endemic focus in southern Islamic Republic of Iran

This study aimed to carry out a malaria situation analysis, species composition and susceptibility levels of the main malaria vector, Anopheles stephensi, to different insecticides in Bashagard. A longitudinal survey was conducted in 2 randomly selected villages in Bashagard. Malaria vectors were sampled by dipping method for the larvae and hand catch, night-biting catch, total catch, and shelter pit collection for the adults. Standard WHO susceptibility tests were used for a variety of insecticides on F1 progeny of An. stephensi reared from wild-caught females. In total, 693 adult anopheline mosquitoes and 839 third and fourth-instar larvae were collected and identified. They comprised 7 species; the most abundant adult and larvae anopheline mosquito was An. dthali (40.7% and 30.5% respectively). An. culicifacies (24.2%) and An. stephensi (16.7%) were the next most common species for adult mosquitoes. An. stephensi was fully susceptible to malathion and pyrethroid insecticides but resistant to DDT and tolerant to dieldrin.