Comparison of radiation dose, contrast enhancement and image quality of prospective ECG-Gated CT coronary angiography: Single versus dual source CT

INTRODUCTION

The updated National Institute of Clinical Excellence (NICE) guidelines of 2017 state that new generation cardiac CT scanners (Aquilion ONE, Brilliance iCT, Discovery CT750 HD and Somatom Definition Flash) are recommended as an option for first-line imaging of the coronary arteries in people with suspected stable coronary artery disease (with an estimated likelihood of coronary artery disease of 10-29%) in whom imaging with earlier generation CT scanners is difficult. New generation cardiac CT scanners are also recommended as an option for first-line evaluation of disease progression, to establish need for revascularisation in people with known coronary artery disease in whom imaging with earlier generation CT scanners is difficult. CT scanning might not be necessary in situations in which immediate revascularisation is being considered. The European Society of Cardiology 2019 clinical practice guidelines recommend non-invasive functional imaging for myocardial ischaemia or coronary CT angiography (CTA) as the initial test to diagnose CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone. Given increased computed tomography coronary angiogram (CTCA) utilisation, radiation dose, contrast enhancement and image quality of prospective ECG-gated CTCA between 256-slice single-source and 192x2-slice dual-source CT scanners were retrospectively evaluated.

METHODS

Prospectively gated CTCA data from 63 patients on a 256-slice CT (group A) and 71 patients on a 192x2-slice dual source CT (group B) from January to December 2016 were retrospectively evaluated respectively. Scanner-reported dose length product values were used with a conversion factor (k = 0.014 mSv/mGy x cm) to estimate effective dose. Contrast enhancement was assessed with mean CT attenuation at selected regions of interest on axial coronary images. Image quality of the coronary arteries was assessed by a 4-point grading score (1 = non-diagnostic, 4 = excellent image quality).

RESULTS

The radiation doses in group B were significantly lower than group A (3.68 + 2.13 mSv versus 4.81 + 1.56 mSv, p < 0.001). There were no significant differences in contrast enhancement in the left coronary artery, proximal right coronary artery and left ventricular wall for both groups. Vessel image quality scores for group B were higher than group A (right coronary artery (RCA): 3.2 + 0.7 versus 2.4 + 0.7, p < 0.001; left anterior descending (LAD) artery: 3.0 + 0.8 vs 2.5 + 0.6, p < 0.001; left circumflex (LCx) artery: 3.3 + 0.7 vs 2.6 + 0.6, p < 0.001). Coronary artery contour scores for group B were significantly higher than group A (RCA: 3.2 + 0.8 versus 2.3 + 0.7, p < 0.001; LAD: 3.0 + 0.7 versus 2.4 + 0.6, p < 0.001; LCx: 3.3 + 0.6 versus 2.5 + 0.6, p < 0.001).

CONCLUSION

Prospective ECG-gated CTCA performed on 192x2-slice CT results in better image quality and lower radiation dose than 256-slice CT. There were no significant differences in contrast enhancement in left main coronary artery (LMCA), proximal RCA and left ventricular wall in both groups.

IMPLICATIONS FOR PRACTICE

In institutions with both 256-slice and 192x2-slice CT scanners, we recommend that CTCAs be preferentially performed using the 192x2-slice CT scanner.

P5719Plasma proteomics identify plaque-related proteins that predict long-term recurrent coronary events in patients with acute coronary syndrome

Background

Coronary plaque burden and composition drive recurrent ischaemic events in coronary artery disease.

Purpose

We first investigated the association between plasma proteins and coronary plaque characteristics in a cohort of asymptomatic individuals with low-intermediate Framingham Risk Score. Plaque-related proteins were further evaluated in a second cohort of patients with acute coronary syndrome (ACS) to determine their prognostic value for predicting future myocardial infarction (MI).

Methods

We profiled 1305 plasma proteins using an aptamer-based array (SOMAscan) in asymptomatic individuals who had undergone 384-slice coronary computed tomography angiography. Plaques were categorized by composition as calcified or non-calcified. First, we identified proteins that were different (based on multiple testing adjusted p-values: q-value <0.05) between 250 ACS patients who suffered a recurrent MI event on follow-up compared with another 250 ACS patients who remained event-free using Mann-Whitney U test. Next, protein candidates that also correlated (Pearson's p<0.05) with specific categories of plaque composition were evaluated using a cox proportional hazards model to determine the risk of recurrent MI, adjusting for potential confounders in the second cohort.

Results

A total of 65 and 120 plasma proteins were significantly associated with calcified and non-calcified plaques respectively in the asymptomatic cohort (N=79). Of these 185 proteins, 23 proteins were differentially expressed (DE) between ACS patients with and without recurrent MI events (median follow-up 1811 days). The top three up-and down-regulated proteins in the recurrent MI group were macrophage-capping protein, trefoil factor 3 and cystatin-SN (median FC 1.22, 1.17 and 1.17; q-value 4.34x10–6, 2.18x10–4, 3.17x10–3 respectively) and fibroblast growth factor 20, lymphotoxin a2/b1 and vascular endothelial growth factor receptor 2 (median FC 0.92, 0.94 and −0.090; q-value 1.31x10–3, 9.45x10–3 and 3.90x10–3) respectively. The quartiles of these protein concentrations were also associated with risk of recurrent MI, (log-rank test p-value range from 2.71x10–7 to 0.04). Of the DE proteins, the adjusted hazards ratio (HR) of cystatin-SN in the highest quartile (Q4) was 1.44 times that of the first quartile (Q1) (adjusted HR: 1.44, 95% CI: 0.93–2.2) and higher plasma concentration of cystatin-SN was associated with increasing risk of recurrent MI events (Trend test p=0.004). On the other hand, the highest quartile of fibroblast growth factor 20 was associated with 44% reduction in risks of recurrent MI adjusted HR: 0.56, 95% CI of HR: 0.35–0.87), with significant trend test (p=0.0096).

Conclusions

Large-scale plasma proteomics identified novel plaque-related proteins predictive of recurrent coronary events in patients with ACS. Further studies may help unravel the biological underpinnings of these circulating proteins and their potential as novel prognostic biomarkers.

Acknowledgement/Funding

This work was supported by grant NMRC/CSA-INV/0001/2016 from the National Medical Research Council, Singapore.

Abstract PD3-04: PAK-1 amplified breast cancer cell lines are preferentially sensitive to PAK inhibition with G-5555

The small GTP-binding proteins Rac1 and Cdc42 stimulate activity of the serine/threonine kinase p21-activated kinase-1 (PAK-1) to drive growth factor signaling networks and Ras-driven tumorigenesis. Genomic amplification and over-expression of PAK1 are prevalent in luminal breast cancer and correlate with poor clinical outcome. Here we use a novel and selective small molecule inhibitor, G-5555, of the group I PAKs (PAK1, 2, and 3) to evaluate the importance of PAK1 in promoting growth of PAK1 amplified breast cancer cells. Cell lines with amplification of PAK1 were found to be more sensitive to PAK1 inhibition than non-amplified cell lines. Additionally, reverse phase protein array (RPPA) was used to assess the effects of PAK1 inhibition on a wide range of signaling pathways in both amplified and non-amplified cell lines. Reduced levels of phosphorylation of MEK S298 was observed in all cell lines exposed to G-5555 irrespective of amplification status, consistent with PAK1 inhibition in these cell lines. However, modulation of this downstream PAK1 substrate did not correlate with inhibition of cell proliferation or induction of cell death. Cell lines that showed inhibition of proliferation in response to G-5555 also showed enhanced levels of cell death along with apoptosis. Moreover, G-5555 reduced tumor growth in the PAK1 amplified MDA-MB-175 xenograft tumor model. Finally, we compared the in vitro activity of G-5555 with palbociclib, a recently approved inhibitor of the cyclin-dependent kinases CDK4 and CDK6, in PAK1 amplified luminal breast cancer cell lines. Our data supports PAK1 as an attractive target in PAK1 amplified cells and tumors and suggests that inhibiting PAK1 rather than CDK4/6 in this context may be a more attractive therapeutic strategy.

Citation Format: Ong CC, Blackwood E, Jakubiak D, Daemen A, Ramaswamy S, Heise C, Schmidt M, Sanders L, Wilson TR, Huw L, Ndubaku C, Rudolph J, Hoeflich KP, Friedman L, O'Brien T. PAK-1 amplified breast cancer cell lines are preferentially sensitive to PAK inhibition with G-5555. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD3-04.

Zoonotic parasites from exotic meat in Malaysia

Four zoonotic parasites, Sarcocystis spp., Toxoplasma gondii, Trichinella spp. and Taenia spp were screened in exotic meats. A total of forty-six (n=46) meat samples from various species of exotic animals were received from all the 14 states in Malaysia from January 2012 to April 2012. All exotic meat samples were examined macroscopically and histologically for the four zoonotic parasites. Results by histological examination of exotic meats showed the presence of Sarcocystis and Toxoplasma cysts at 8.7% (n=4) and 4.3% (n=2) respectively. No Trichinella spp. and Taenia spp. were found.

Eleven novel polymorphic microsatellite DNA markers from the green-lipped mussel Perna viridis

We report on the characterization of 11 polymorphic microsatellite loci in P. viridis, the first set of such markers developed and characterized for this species. The number of alleles per locus ranged from 2 to 7, whereas the observed heterozygosity ranged from 0.0447 to 0.4837. These markers should prove useful as powerful genetic markers for this species.

A rare case of a pedunculated lipoma in the pharynx

While lipomas on the trunk and limbs are common, they are rare in the upper aerodigestive tract. A case is reported of an 18 cm long pedunculated lipoma arising from the hypopharynx in a 73 year old man. The tumour was asymptomatic until it appeared in the mouth of the patient after a coughing episode.

Extraluminal migration of a coin in the oesophagus of a child misdiagnosed as asthma

Ingestion of a foreign body, the commonest being a coin, is a common problem in children. In most cases the coin will pass uneventfully through the gastrointestinal tract. However, on rare occasions it may become lodged in the oesophagus with subsequent extraluminal migration with the potential for serious complications such as vascular fistula or chronic suppurative infection. A case is presented of extraluminal migration of a coin in the oesophageal associated with abscess formation in a 15 month old boy. This case is particularly important because the presenting symptom of wheezing led to the erroneous diagnosis of asthma, which resulted in a three month delay in investigation and treatment. In addition, it raises the issue of whether to perform chest radiography on newly diagnosed asthmatic patients to rule out the presence of a foreign body and thereby prevent serious complications.

Pharyngeal pouch endoscopic stapling--are post-operative barium swallow radiographs of any value?

Posterior pharyngeal pouch endoscopic stapling has gained increasing popularity among otolaryngologists especially in elderly patients. Post-operative barium swallow appearances can create confusion with the appearance of persistent pouches. We describe our experience in 10 patients, three of whom had external excision with cricopharyngeal myotomy and the remaining seven had endoscopic stapling approach. All three patients who had external excision showed no residual pouch whereas all seven patients who had endoscopic techniques performed showed some residual pouch. We were unsuccessful in our attempt to correlate post-operative symptoms with radiological appearance. Attempts by other radiologists at identifying pre- and post-operative barium swallow radiographs in patients who had endoscopic stapling of pharyngeal pouch were unsuccessful. We conclude that post-operative barium swallow radiography plays no role in determining the success of endoscopic stapling of pharyngeal pouch.

The difficulties encountered in completing an audit cycle in a district general hospital

Clinical audit has brought about tremendous improvements in the quality of clinical practice in all aspects of health care. However, completing an audit cycle presents many obstacles. We present our experience in the difficulties encountered in implementing changes to current practice. The factors involved are discussed.

Cellular proteins bind to the 3' and 5' untranslated regions of dengue 2 virus genome

In vitro generated cloned full length dengue 2 virus untranslated regions (UTRs) were used in RNA gel mobility shift assays to examine cellular factors binding to the virus genomes. Cellular factors in lysates of Vero (monkey) and C6/36 (mosquito) cells bound specifically and non-specifically to the dengue 2 virus 3' UTR. Non-specific interaction with the 5' UTR, resulting in formation of at least 4 band shift complexes was noted with lysate of the C6/36 cells only. Pre-treating the cell lysates with proteinase K affected binding of cellular factors to the dengue 2 virus UTRs, suggesting that the cellular factors were proteins. These findings suggest that cellular proteins could interact with specific sites on the dengue virus genomes.

Spectral studies of magnesium porphyrin--apomyoglobin and apohemoglobin complexes

Complexes of magnesium protoporphyrin and magnesium mesoporphyrin with apomyoglobin and apohemoglobin have been prepared and studied by electronic, circular dichroism, and optical rotatory dispersion spectroscopy. The myoglobin complexes show prominent splittings and red shifts of the visible absorption bands, with respect to those for the hemoglobin analogs. Comparisons are made with other heme protein systems that display similar spectral features. Different reasons for the observations are considered, including multiple conformer formation, polarity effects of the protein environment, and the formation of six-coordinate magnesium species through H2O coordination for the Mb complexes (the latter explanation being favored).