Abnormal fractional flow reserve and non-hyperaemic pressure ratios in patients with severe aortic stenosis and non-obstructive coronary artery disease

Background

Fractional flow reserve (FFR) and non-hyperaemic pressure ratios (NHPRs) are well-validated tools that assess the physiological significance of coronary artery disease (CAD). Low coronary lumen to myocardial mass (V/M) ratio on CT is associated with lower FFR/NHPRs and predisposes towards ischaemia in CAD. Whilst CAD and aortic stenosis (AS) frequently co-exist, patients report angina despite obstructive disease.

Purpose

We therefore sought to study the interrelationship between V/M and invasive pressure indices in patients with severe AS.

Methods

35 patients with severe AS were prospectively recruited as part of CAST-FFR study. Patients underwent CT coronary angiography and invasive pressure-wire assessment. All pressure-indices were assessed in the left anterior descending artery (LAD). Data was extracted to calculate FFR, iFR, diastolic pressure ratios (DPR and dPR) and Diastolic Hyperaemia-free Ratio (DFR). Patient-specific V/M were extracted off-site by independent core lab.

Results

Mean age was 75±7.5 years, median V/M ratio was 20.7 and mean aortic gradient and DI were 44.3±11.6mmHg and 0.23±0.4 respectively. 79% of patients had CADRADs score of <2. There were moderate positive correlations between FFR/NHPRs and V/M, including FFR (r=0.60), PdPa (r=0.48), iFR (r=0.59), DPR (r=0.59), dPR (r=0.63), DFR (r=0.67), (all p<0.005). In patients with positive pressure assessments, 69% (FFR), 71% (iFR), 70% (DPR) and 65% (DFR) had CADRADs score <2. In severe AS, lower V/M was associated with lower pressure-indices (FFR 0.75 vs 0.86, iFR 0.79 vs 0.92, DFR 0.80 vs 0.91, all p<0.005), leading to high rates of positive physiologic assessment (FFR 88%, PdPa 72%, iFR 67%, DPR 78%, DFR 74%).

Conclusion

Patients with severe AS exhibit high rates of abnormal FFR and NHPR values, despite having no obstructive CAD. Their propensity for having abnormal physiological results is, in part, influenced by coronary volume to mass ratio. These results are important for clinicians considering using invasive physiological tools to guide revascularisation decisions in patients with severe AS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Monash University, Cardiac Society of Australia and New Zealand Correlation between NHPR/FFR and VMInvasive pressure indices and VM

Association between prosthesis geometry and leaflet thrombosis following transcatheter aortic valve replacement

Introduction

Leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is a recognised condition. The association between prosthesis geometry [expansion, implant depth and commissural alignment (CA)] and LT is unclear.

Methods

Patients that received intra-annular TAVR prosthesis and post-procedure computed tomography (CT) with a 320-slice scanner were included. LT, defined as at least 50% restricted leaflet motion, was assessed with a dedicated 3Mensio workstation by two experienced CT readers. Prosthesis expansion was defined as actual divided by expected prosthesis area as a percentage of expected area whilst eccentricity was [(maximum diameter − minimum diameter) / maximum diameter) × 100%], both measured at prosthesis inflow, annulus and outflow. Implant depth was the average distance between prosthesis inflow and nadir of each cusp. CA was the average angle between each native and prosthesis leaflet coaptations. Significant commissural misalignment (CMA) was defined as CA greater than 30 degrees. To exclude anticoagulation bias, similar analysis was also performed in the cohort of non-anticoagulated patients.

Results

117 patients were included; the prevalence of LT was 13.7% [13/93 cases (14.0%) of Lotus valves and 3/24 cases (12.5%) of Sapien 3 valves]. Baseline demographics (age, STS score, cardiac risk factors) and procedural characteristics (access site, post-dilation, repositioning) were similar in both groups. None of the patients with LT were discharged on anticoagulation therapy (0.0% vs 22.8%, p<0.01). There were no differences in actual prosthesis area, perimeter or eccentricity at the three prosthesis levels. Patients with LT had reduced annulus expansion (89.3±9.8% vs 94.6±8.3%, p=0.02), lower implant depth (6.9±1.5mm vs 4.9±1.5mm, p<0.01) and more significant CMA (81.3% vs 48.5%, p=0.02). These findings were similar in patients that were not anticoagulated (94/117 patients).

Conclusion

Patients with LT had reduced annulus expansion, lower implant depth and greater CMA. These findings were not affected by presence or absence of anticoagulation. These factors may be important considerations during procedural planning for TAVR.

Graphical abstract

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council (NHMRC). National Heart Foundation (NHF) Australia.

Preventing accidents in the offshore Oil and Gas industry: An interrupted time series analysis

Background

Oil and Gas industry suffers from high accident rates because of the dangerous working conditions. Eastern Mediterranean countries have an immature Oil and Gas industry and therefore it is crucial for preventing accidents in this early stage to implement internationally proven successful policies. The aim of this study was to investigate whether the accident prevention policies implemented by Norwegian government in 2001 were effective in reducing accident rates in the offshore Oil and Gas industry.

Methods

Data on the number of accidents, dates and type of facility (fixed or movable) for the years 1999-2006 were obtained from the Norwegian Petroleum Safety Authority (PSA). The effectiveness of the policy to reduce accident rates was estimated in interrupted time series analysis with post-intervention period the 1st of January 2001. Poisson regression was used to model the number of accident per months.

Results

The dataset had 96 months with a median number of accidents per month 6.5 (IQR: 4-10) for fixed facilities and 5.0 (IQR: 3-9) for movable facilities. The analysis suggested that there was a reduction in accident rates for fixed and movable facilities. Following the policy, there was a reduction in accidents of 45% for fixed facilities (rate ratio (RR) 0.55; 95% confidence interval (CI) 0.47-0.64), while for movable facilities there was a decrease of 67% (RR 0.33; 95% CI 0.28-0.39).

Conclusions

The policies implemented by Norwegian government in 2001 were effective in reducing the accident rates for fixed and movable facilities. The immature Oil and Gas industry of the Eastern Mediterranean countries will be benefited from studying and adopting some of the policies implemented by Norwegian government.

Key messages

Norwegian policies for accident prevention in the offshore Oil and Gas industry were successful. Oil and Gas industry of Eastern Mediterranean countries should adopt proven successful policies to prevent accidents.

Social anxiety disorder and shame cognitions in psychosis

BACKGROUND

Social anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.

METHOD

This was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status.

RESULTS

Shame proneness (p < 0.01) and loss of social status (p < 0.01) were significantly elevated in those with SAD (with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis and social anxiety expressed significantly greater levels of shame (p < 0.05), rejection (p < 0.01) and appraisals of entrapment (p < 0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety.

CONCLUSIONS

These findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being 'ill' is needed.

The value of sex hormone binding globulin (SHBG) in predicting treatment response in polycystic ovary syndrome (PCOS)

BACKGROUND

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterised by chronic anovulation, hyperandrogenism and polycystic ovaries on ultrasound. Patients commonly show features of the metabolic syndrome and insulin resistance. It has been shown that treatment with the insulin sensitising agent metformin can lead to improvements in symptoms in some but not all patients. The aim of the study was to assess whether sex hormone binding globulin (SHBG) (a surrogate marker of insulin resistance) could predict a positive response to metformin treatment in women with PCOS.

METHODS

Medical notes of patients who presented to the gynaecology clinic at Southmead Hospital, Bristol with suspected PCOS were reviewed. Data collected included clinical symptoms and signs of hyperandrogenism, markers of PCOS in the family and obstetric history, biochemical markers and outcome of any treatment.

RESULTS

A total of 66 patients were included in the study; 45 were classified as PCOS positive. In this group, patients who responded to metformin treatment had significantly lower SHBG levels compared to those who did not (median SHBG 37.5 nmol/L compared to 56.0 nmol/L) (p = 0.016, Mann-Whitney U-test). Patients with lower SHBG tended to have a better treatment outcome than those with higher values (odds ratio 0.983, 95% confidence interval 0.963-1.002, p = 0.079).

CONCLUSIONS

Patients with a positive response to metformin treatment had significantly lower pre-treatment SHBG levels. For every unit increase in SHBG, the odds of a patient having a positive outcome to metformin treatment fell by a factor of 0.983.

Post Operative Analgesia for Breast Surgery: Intercostal Nerve Block Versus Subcutaneous Infiltration

BackgroundPost operative analgesia is often underestimated in breast surgery resulting in long term sequelae. Opiates and epidural analgesia may produce complications and limits early rehabilitation. We compare the effects of intercostal nerve block with subcutaneous infiltration as post operative analgesia in breast surgery.MethodsAll patients who undergo breast surgery were assigned to two groups. They either receive intercostal nerve block or subcutaneous infiltration of 0.5% bupivacaine at the end of surgery. Pain score using visual analogue scale and the total amount of morphine consumption were recorded. Personnel taking measurements were kept blind.ResultsThere were 70 patients included in the study. Of these, three patients (two from Group A and one from Group B) were excluded because of post operative haematoma and drain related complications. 33 patients had intercostal nerve block and 34 patients received subcutaneous infiltration. The groups were comparable with respect to age and type of breast surgery. There were significant differences in the visual analogue pain scores at the early post operative period in the study group (P value of &lt; 0.05).Table 1Pain ScoreGroup A Median (range)Group B Median (range)No. of patientsP valueWith in 4 hr of surgery2 (1-8)2 (1-9)330.7521st post op 8am2 (1-6)3 (1-8)330.0091st post op 6pm2 (1-6)2 (1-10)330.0112nd post op 8am1 (1-5)2 (1-8)120.2442nd post op 6pm1 (1-4)1.5 (1-5)110.2213rd post op 8am1 (1-4)1 (1-6)90.1373rd post op 6pm1 (1-7)2 (1-4)90.347 ConclusionsWe have demonstrated in our study that intercostal nerve block provides effective post operative analgesia in breast surgery patients. The accessibility of intercostal nerves in the operative field makes blockade feasible. Contrary to the misconception, incidence of pneumothorax is very rare. It should therefore be used more widely in view of its simplicity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5052.

A fatal case of sclerosing mesenteritis

A 22-year-old patient was admitted because of abdominal pain and vomiting. Computed tomography diagnosed small intestinal malignancy. Ileal resection was performed, and the histological findings were consistent with sclerosing mesenteritis. The patient was treated with enteral nutrition, corticosteroids, azathioprine and methotrexate, but died 2 years later.

Evaluation of different MCQ-scoring-system in a medical school

The MCQ scores of final medical students in surgery for the years 1990 and 1991 were analysed. The score for a correct answer was plus 1 mark in both years. The penalty for incorrect answer for the year 1990 was minus-1 mark as had been practiced during the previous 15 years. The penalty for the year 1991 was minus 1/4 for an incorrect answer. This low penalty of minus 1/4 resulted in an inflated MCQ score as compared with the essay questions and both clinical and oral examination results. The low score recorded during the year 1990 is a genuine reflection of inadequate performance rather than bad evaluation since the MCQ bank is the same and the panel of examiners has not changed. It is concluded that minus 1 mark penalty has many advantages and therefore should be the practice.