Catheter ablation for atrial fibrillation in adult congenital heart disease: an international registry study

Background

Life expectancies for patients with congenital heart disease (CHD) have dramatically increased in recent years, accompanied by a rise in atrial fibrillation (AF) prevalence. Data on AF ablation strategy and outcomes are limited in CHD.

Purpose

We aimed to investigate the characteristics of CHD patients presenting for AF ablation and their outcomes.

Methods

A multicenter, retrospective analysis was performed of CHD patients undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using the 2014 PACES/HRS guidelines. Clinical data were collected including ablation strategy and follow up. One-year procedural success was defined as freedom from AF in the absence of antiarrhythmic drugs (AADs, complete) or including previously failed AADs (partial).

Results

Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±0.9 years. CHD complexity categories included 147 (61.3%) simple, 69 (28.8%) intermediate and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had AF despite at least one AAD. 46 patients (22.1%) had a reduced systemic ventricular ejection fraction <50%, and the mean left atrial diameter was 44.1±0.7 mm. PV isolation (PVI) was performed in 227 patients (94.6%); additional ablation strategies included left atrial linear ablations (25.4%), CFAE (19.2%), and cavotricuspid isthmus ablation (40.8). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications.

Conclusion

AF ablation in this complex population was safe and resulted in AF control in the majority of patients. Future work should address the most appropriate ablation targets in the challenging population.

Funding Acknowledgement

Type of funding sources: None.

1060 Surgical Currency - the Link Between Skill Fade and Safe Practice

Aim

Surgical currency refers to the operating time required per year before a surgeon's skill fade could negatively affect patient outcomes. Increased surgical experience and volume of operating hours directly improves patient outcomes. There is no clear guidance from the NHS or Defence Medical Services on amount of experience needed to maintain current. This paper highlights the importance of surgical currency, investigates if skill fade occurs faster than knowledge, and looks to ensure surgeons are not deployed beyond the point of currency. It explores methods to prevent skill fade and reintegrate surgeons following absence.

Method

A thorough literature search was performed. Currency protocols across Royal Colleges, healthcare systems and other industries were studied, including systems installed to mitigate skill fade during COVID-19.

Results

An average deployment for a military surgeon will be three months, but pre-deployment training can make this six. The AMRC states an absence over three months affects medical knowledge. Skill fade occurs more rapidly than knowledge, but research remains limited for how long a well-practiced skill is retained. The aviation industry clearly stipulates a pilot's currency, and simulator training is provided following absence. US surgical simulator training proved effective in maintaining skills during the pandemic. Health Education England and Royal College of Surgeons Edinburgh provides return programs for trainees but not consultants.

Conclusions

Careful consideration should be given before extending surgical deployments. Surgical simulation could be used while deployed to maintain currency. Return-to-work programs should be available to consultants. Further research should be done on currency and prevention of skill fade.

Raman Interferometry between Autoionizing States to Probe Ultrafast Wave-Packet Dynamics with High Spectral Resolution

Photoelectron interferometry with femtosecond and attosecond light pulses is a powerful probe of the fast electron wave-packet dynamics, albeit it has practical limitations on the energy resolution. We show that one can simultaneously obtain both high temporal and spectral resolution by stimulating Raman interferences with one light pulse and monitoring the modification of the electron yield in a separate step. Applying this spectroscopic approach to the autoionizing states of argon, we experimentally resolved its electronic composition and time evolution in exquisite detail. Theoretical calculations show remarkable agreement with the observations and shed light on the light-matter interaction parameters. Using appropriate Raman probing and delayed detection steps, this technique enables highly sensitive probing and control of electron dynamics in complex systems.

Autoionizing Polaritons in Attosecond Atomic Ionization

Light-induced states and Autler-Townes splitting of laser-coupled states are common features in the photoionization spectra of laser-dressed atoms. The entangled light-matter character of metastable Autler-Townes multiplets, which makes them autoionizing polaritons, however, is still largely unexplored. We employ attosecond transient-absorption spectroscopy in argon to study the formation of polariton multiplets between the 3s^{-1}4p and several light-induced states. We measure a controllable stabilization of the polaritons against ionization, in excellent agreement with ab initio theory. Using an extension of the Jaynes-Cummings model to autoionizing states, we show that this stabilization is due to the destructive interference between the Auger decay and the radiative ionization of the polaritonic components. These results give new insights into the optical control of electronic structure in the continuum and unlock the door to applications of radiative stabilization in metastable polyelectronic systems.

POS0838 EPIDEMIOLOGY AND TRENDS IN SURVIVAL OF SYSTEMIC SCLEROSIS IN OLMSTED COUNTY: A POPULATION-BASED STUDY (1980-2018)

Background:

Systemic sclerosis (SSc) is a complex immune-mediated disease with heterogeneous manifestations, which is characterized by vasculopathy and fibrosis of the skin and visceral organs. Mortality associated with SSc exceeds that of other rheumatic diseases, though population-based studies assessing recent trends in survival are lacking.

Objectives:

We aimed to determine the incidence and prevalence of physician-diagnosed SSc in a population-based cohort over a 39-year time period, and assess for trends in survival over time.

Methods:

Medical records of patients with a diagnosis or suspicion of SSc in a geographically well-defined area from Jan 1, 1980 to Dec 31, 2018 were reviewed to identify incident cases of SSc. Cases were defined by physician diagnosis of SSc, and fulfillment of the 2013 ACR/EULAR classification criteria was ascertained. Prevalent cases of SSc on Jan 1, 2015 were also identified. Incidence and prevalence rates were age- and sex-adjusted to the 2010 U.S. white population. Survival rates were compared with expected rates in the general population.

Results:

85 incident cases of SSc (91% female, mean age 55.4 ± 16 y) and 49 prevalent cases on Jan 1, 2015 were identified. Patients had a mean 11.7 (SD 9.4) years of follow-up available. The overall age and sex adjusted annual incidence for 1980-2018 was 2.5 (95% CI: 2.0-3.1) per 100,000 population, with no change in incidence over time (p=0.32). The age-adjusted incidence was 4.4 (95% CI: 3.4-5.4) for females, and 0.56 (95% CI: 0.16-0.96) for males per 100,000 population. The age- and sex-adjusted prevalence on Jan 1, 2015 was 43.6 (95% CI: 31.3-55.8) per 100,000 population.

77 (91%) patients fulfilled the 2013 classification criteria; 38 (45%) fulfilled 1980 criteria. 70 (82%) had limited cutaneous involvement, 12 (14%) had diffuse cutaneous involvement, and 3 (4%) had sine scleroderma. At SSc diagnosis, 80 (94%) patients had Raynaud’s, 43 (51%) had sclerodactyly, 39 (46%) had telangiectasias, 14/48 (29%) had abnormal nailfold capillaries, 16/35 (46%) had digital ulcers or fingertip scarring, 8 (9%) had interstitial lung disease (ILD), and 7 (8%) had pulmonary arterial hypertension (PAH). 77/82 patients (91%) had a positive antinuclear antibody. 44 (52%) had a known SSc-related autoantibody: 32 (73%) with anti-centromere, 9 (20%) with anti-Scl-70, and 4 (9%) with anti-RNA-polymerase III.

Survival was 77% (95% CI: 69-87) at 5 years, 66% (95% CI: 56-78) at 10 years, and 42% (95% CI: 30-57) at 20 years, with no evidence of improved survival over time (p=0.46). Age (Hazard ratio [HR]: 1.49 per 10 year increase; 95% CI 1.19-1.88), smoking at time of diagnosis (HR: 2.37; 95% CI: 1.05-5.34), digital ischemia (HR: 2.54; 95% CI: 1.33-4.87), ILD (HR: 4.00; 95% CI: 2.11-7.59), and PAH (HR: 4.30; 95% CI: 2.24-8.25) had significant associations with mortality. Survival of patients with SSc was poorer than the general population (standardized mortality ratio: 2.48; 95% CI: 1.76-3.39).

Conclusion:

The average incidence of SSc in this population-based cohort spanning 39 years was 2.5 per 100,000 population, with no change in incidence over time. Age, smoking, digital ischemia, ILD and PAH were risk factors for poorer survival. Overall survival for patients with SSc is worse than that of the general population and shows no improvement over time, suggesting continued need for improved diagnostic and treatment measures.

Figure 1.

Survival of 85 Olmsted County residents with SSc compared with expected survival rates from Minnesota lifetables (observed: solid line, expected: dashed line).

Disclosure of Interests:

None declared

POS0836 CONDUCTION AND RHYTHM DISORDERS AMONG PATIENTS WITH SYSTEMIC SCLEROSIS: A US POPULATION BASED STUDY

Background:

Systemic sclerosis (SSc) can impact multiple areas of the heart through fibrotic and vascular processes; leading to variable cardiac involvement including electrocardiogram (ECG) abnormalities. Conduction and rhythm disorders are associated with worse prognosis in patients with SSc. (1, 2)

Objectives:

To study the incidence, risk factors and outcomes of conduction and rhythm disorders in a US population-based cohort of patients with SSc and non-SSc comparators from the same geographic area.

Methods:

A previously identified incident cohort of SSc patients (1980-2016) in a well-defined geographic area was compared to a randomly selected 2:1 cohort of age- and sex-matched non-SSc subjects from the same population base. Demographics, disease characteristics, cardiovascular risk factors and laboratory tests were abstracted by manual record review. ECGs and Holter ECGs were reviewed to determine the occurrence of any conduction or rhythm abnormalities. The need for cardiac interventions was also abstracted.

Results:

78 incident SSc cases and 156 non-SSc comparators were identified [age 56 years± 15.7, 91% female]. Prevalence of any conduction disorders before SSc diagnosis compared to non-SSc comparators was 15% vs. 7% (p=0.06), and any rhythm disorder was 18% vs. 13% (p=0.33). During a median follow up of 10.5 years in patients with SSc and 13.0 years in non-SSc comparators, conduction disorders developed in 25 SSc patients with a cumulative incidence (ci) of 20.5% (95% CI: 12.4-34.1%) compared to 28 non-SSc patients with ci of 10.4% (95% CI: 6.2-17.4%) (HR: 2.57; 95% CI: 1.48-4.45), while rhythm disorders developed in 27 SSc patients with ci of 27.3% (95% CI: 17.9-41.6%) vs 43 non-SSc patients with ci of 18.0% (95% CI: 12.3-26.4%) (HR: 1.62; 95% CI: 1.00-2.64). (Figure 1).

Conduction disorders in patients with SSc during follow up included: 1st-degree atrioventricular block (AVB) (n=12), 2nd-degree AVB (n=1), 3rd-degree AVB (n=1), right bundle branch block (n=10), left bundle branch block (n=4), bifascicular block (n=6), and prolonged-QT (n=13). Rhythm disorders included: atrial fibrillation (n=10), atrial flutter (n=4), supraventricular tachycardia (n=4), ventricular tachycardia (n=1), and premature ventricular contractions (n=16).

Pulmonary hypertension (PHT) was the only significant risk factor identified for development of both conduction and rhythm disorders (HR=8.38, 95% CI: 1.32-53.40 and HR=8.07, 95% CI: 1.60-40.74, respectively). Current smoking significantly increased the risk for development of rhythm disorders (HR=2.91, 95% CI: 1.19-7.12). Conduction and rhythm disorders were associated with increased mortality among patients with SSc (HR=7.60, 95% CI: 3.49-16.55 and HR=4.87, 95% CI: 2.28-10.42, respectively, after adjusting for age, sex and calendar year of diagnosis).

Conclusion:

Patients with SSc have a significantly higher prevalence of conduction disorders at disease onset than non-SSc comparators. During the course of their disease, their risk of developing conduction disorders is 2.6-fold, and risk of rhythm disorders is 1.6-fold increased, compared to non-SSc subjects.

PHT was significantly associated with increased risk of developing conduction and rhythm disorders among patients with SSc, a finding that should warrant increased vigilance and screening for ECG abnormalities in this population.

References:

[1]Tyndall A.J. et al. Ann Rheum Dis, 2010. 69(10): p. 1809-15.

[2]Desai C.S. et al. Curr Opin Rheumatol, 2011. 23(6): p. 545-54.

Figure 1.

Cumulative incidence of any conduction or any rhythm disorder in SSc (solid line) vs non-SSc comparators (dashed line).

Disclosure of Interests:

None declared

A134 A MULTI-CENTRE RANDOMIZED CONTROLLED TRIAL TO COMPARE TWO BOWEL CLEANSING REGIMENS AFTER A COLONOSCOPY WITH INADEQUATE BOWEL PREPARATION

Aims

Failed bowel preparation is common during colonoscopy, yet the optimal purgative regimen to use for the next attempt is unknown. The objective of this study was to compare the efficacy, tolerability, and safety of two regimens at supratherapeutic doses for use after failed bowel preparation.

Methods

A multi-centre phase III endoscopist blinded randomized controlled trial (NCT02976805) was conducted in patients who failed bowel preparation, using the US Multi-Society Task Force (USMSTF) definition of inability to exclude polyps >5 mm in size and requiring a shortened interval to next colonoscopy. Regimen A consisted of 15 mg of bisacodyl and 2 + 2 L of split dose polyethylene glycol electrolyte solution (PEG) and Regimen B consisted of 15 mg of bisacodyl and 4 + 2 L of split dose PEG. The primary outcome was adequate bowel preparation, defined as a Boston Bowel Preparation Scale (BBPS) total score ≥ 6 with all segment scores ≥ 2. Secondary outcomes were adequate bowel preparation using the USMSTF definition, median BBPS, adenoma detection (ADR), advanced adenoma detection (aADR), sessile serrated polyp detection (SSPDR), and cecal intubation (CIR). Adverse events were assessed at the time of the colonoscopy and 14 days later.

Results

Between February 2017 and December 2019, 250 subjects were screened at four academic centres in Canada, of which 195 were randomized: 96 to Regimen A and 99 to Regimen B. The mean (SD) age was 60.6 (11.4) years, 87 (45.1%) were female, and the median (IQR) total BBPS score at previous failed colonoscopy was 3 (1,4). Regimen B was not superior to Regimen A in achieving adequate bowel preparation using the BBPS definition (87.6% vs. 91.1%, p=0.45) or the USMSTF definition (85.4% vs 91.1%, p=0.24), nor was it superior with respect to the median BBPS score (7 vs 7, p=0.50), mean ADR (31.5% vs 37.8%, p=0.37), aADR (11.2% vs 18.9%, p=0.15), SSPDR (5.6% vs 8.9%, p=0.40) or CIR (92.1% vs 96.7%, p=0.19). Regimen A had a higher adherence rate (88.2% vs. 74.7%, p=0.02) and greater willingness to undergo the bowel preparation again (91.2% vs. 66.2%, p<0.001). The only serious adverse event occurred in a patient randomized to Regimen B who was admitted to hospital for vomiting after colonoscopy.

Conclusions

Split dose 4L PEG with 15mg of bisacodyl is highly efficacious, well tolerated, and can be used for patients who previously failed first line bowel preparations. The additional 2L of PEG in Regimen B did not improve bowel preparation and was not as well tolerated.

Funding Agencies

AMOSO Opportunities Grant, Pharmascence Inc.

Clinical outcomes after faecal microbiota transplant by retention enema in both immunocompetent and immunocompromised patients with recurrent Clostridioides difficile infections at an academic medical centre

BACKGROUND

Recurrent Clostridioides difficile infection (CDI) is one of the most common and challenging infections to treat in healthcare facilities. Faecal microbiota transplantation (FMT) is recommended as a definitive treatment option.

METHODS

We performed a retrospective review of 50 patients from January 2015 to December 2019 who underwent FMT for recurrent CDI. Primary outcome was recurrence of CDI within 12-weeks of FMT and secondary outcomes were the need for repeat FMT, serious adverse outcomes related to FMT and all-cause mortality.

RESULTS

Fifty charts were reviewed, of which 47 cases comprising 17 immunocompromised patients treated with FMT via retention enema were included in the study. The majority of the patients had ≥3 recurrent CDIs (62%). Nine (19%) patients failed to respond to the first FMT and five underwent repeat FMT within four to 12 weeks. The cure rate was 81% after the first FMT (38/47) and 91% after the second FMT treatment (43/47). Serious adverse events occurred in 2% and all-cause mortality was 2% at 90-day follow up.

CONCLUSION

Our study demonstrated the safety and efficacy of FMT administered via retention enema, a simple bedside procedure, for the treatment and prevention of recurrent non-severe and severe CDI with an overall cure rate of 91%.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

0614 Diurnal Patterning of Autonomic Measures in Sleep Apnea and Paroxysmal Atrial Fibrillation and Response to Continuous Positive Airway Pressure Therapy

Introduction

Diurnal patterning of autonomic function in paroxysmal atrial fibrillation (PAF) and sleep disordered breathing (SDB) is unknown. We hypothesize heart rate variability (HRV) as surrogates of autonomic function, exhibit diurnal differences in PAF relative to SDB severity and treatment.

Methods

We leveraged the Sleep Apnea and Atrial Fibrillation Biomarkers and Electrophysiologic Atrial Triggers (SAFEBEAT,NCT02576587) study focused on participants with PAF and SDB (apnea hypopnea index,AHI≥15,3% oxygen desaturation hypopnea). Attended 16-channel polysomnography (PSG) and continuous ECG monitoring (Heartrak Telemetry®) for 7-21 days was performed at baseline and after 3-months of continuous positive airway pressure (CPAP). Linear mixed-effects models (least square means,95%CI) were used to assess relationships between daily average HRV measures (frequency domain:LF,HF,LF/HF;time domain:MNN,RMSSD,SD1,SD ratio and novel non-linear:DFA-alpha measures) with SDB (AHI),%sleep time with SaO2<90%(TRT<90): per 5-unit increase),effect of 3-month CPAP relative to sleep-wake and statistical interaction of sleep-wake. Analyses were conducted using SAS version v.9.4, Cary, NC.

Results

The analytic sample was comprised of 33 cases with PAF and SDB:61.1±11.7 years,62.5% male, BMI:33.9±7.2kg/m2,75% Caucasian,AHI 15.1 (IQR: 4.4,29.4) and 68.8% on atrioventricular nodal blocking medications. AHI was associated with frequency (HF:0.08[0.01,0.16] and LF/HF:-0.11[-0.20, -0.01]), time (SD1:0.08[0.02,0.14] and SD ratio: 0.09[0.04,0.14]) and non-linear (DFA-alpha1: -0.02[-0.036,-0.003]) domain measures during wake, but not sleep. Significant sleep-wake and AHI as well as TRT<90 interactions relative to HRV measures were observed (p≤0.001). Only SD ratio was associated with TRT<90 (0.12[0.03,0.24]). Baseline to follow-up CPAP time domain measures were altered mainly during wake versus sleep with MNN increased 0.13: [0.08,0.19],p<0.001; RMSSD increased 0.13 [0.08,0.19], p<0.001; SD1 increased 30% [0.09,0.55], p=0.004; SD ratio increased 20% [0.01,0.43], p=0.033,and also frequency domain: HF increased 33%[0.03,0.72], p=0.028.

Conclusion

SDB defined by AHI--more so than nocturnal hypoxia--was associated with surrogate autonomic measures impacted by CPAP intervention during wake and not sleep in PAF. SDB-related autonomic influences in PAF appear to be more pronounced during wakefulness suggesting long-term potentiation-like influences.

Support

This study was supported by the National Heart, Lung and Blood Institute (NHLBI) [Grant R01 HL108493] and National Institutes of Health (NIH) National Center for Research Resources [Grant UL1 RR024989]

High photosensitivity few-layered MoSe2 back-gated field-effect phototransistors

In this paper, we report on the fabrication and optoelectronic properties of high sensitive phototransistors based on few-layered MoSe2 back-gated field-effect transistors, with a mobility of 19.7 cm² V⁻¹ s⁻¹ at room temperature. We obtained an ultrahigh photoresponsivity of 97.1 AW⁻¹ and an external quantum efficiency (EQE) of 22 666% using 532 nm laser excitation at room temperature. The photoresponsivity was improved near the threshold gate voltage; however, the selection of the silicon dioxide as a gate oxide represents a limiting factor in the ultimate performance. Thanks to their high photoresponsivity and external quantum efficiency, the few-layered MoSe2-based devices are promising for photoelectronic applications.

Gate dependent Raman spectroscopy of graphene on hexagonal boron nitride

Raman spectroscopy, a fast and nondestructive imaging method, can be used to monitor the doping level in graphene devices. We fabricated chemical vapor deposition (CVD) grown graphene on atomically flat hexagonal boron nitride (hBN) flakes and SiO2 substrates. We compared their Raman response as a function of charge carrier density using an ion gel as a top gate. The G peak position, the 2D peak position, the 2D peak width and the ratio of the 2D peak area to the G peak area show a dependence on carrier density that differs for hBN compared to SiO2. Histograms of two-dimensional mapping are used to compare the fluctuations in the Raman peak properties between the two substrates. The hBN substrate has been found to produce fewer fluctuations at the same charge density owing to its atomically flat surface and reduced charged impurities.

Spinal 5-HT3 receptors facilitate behavioural hypersensitivity induced by elevated calcium channel alpha-2-delta-1 protein

BACKGROUND

Peripheral nerve injury induces up-regulation of the calcium channel alpha-2-delta-1 proteins in the dorsal root ganglia and dorsal spinal cord that correlates with neuropathic pain development. Similar behavioural hypersensitivity was also observed in injury-free transgenic (TG) mice over-expressing the alpha-2-delta-1 proteins in neuronal tissues. To investigate pathways regulating alpha-2-delta-1 protein-mediated behavioural hypersensitivity, we examined whether spinal serotonergic 5-HT3 receptors are involved similarly in the modulation of behavioural hypersensitivity induced by either peripheral nerve injury in a nerve injury model or neuronal alpha-2-delta-1 over-expression in the TG model.

METHODS

The effects of blocking behavioural hypersensitivity in these two models by intrathecal or systemic injections of 5-HT3 receptor antagonist, ondansetron, were compared.

RESULTS

Our data indicated that the TG mice displayed similar behavioural hypersensitivities to non-painful mechanical stimulation (tactile allodynia) and painful thermal stimulation (thermal hyperalgesia) as that observed in the nerve injury model. Interestingly, tactile allodynia and thermal hyperalgesia in both models can be blocked similarly by intrathecal, but not systemic, injection of ondansetron.

CONCLUSIONS

Our data suggest that spinal 5-HT3 receptors are likely to play a role in alpha-2-delta-1-mediated behavioural hypersensitivities through a descending serotonergic facilitation.

Prognostic value of cardiac troponins in elderly patients with hip fracture--a systematic review

Cardiac troponins can be elevated in cardiac ischemic conditions or other diseases such as pulmonary embolism or renal failure, where they may predict outcome. We hypothesized that cardiac troponins offer useful prognostic information regarding morbidity and mortality in elderly hip fracture patients undergoing surgical therapy. A literature review was conducted using PubMed and CINAHL plus with full text (EBSCOhost). Articles with original data relating troponins to prognosis in elderly hip fracture patients were reviewed. Studies with patients not undergoing surgery or undergoing elective or nonhip fracture surgery were excluded. Six papers met inclusion criteria. Troponin elevation was seen in 26.7-39% of patients, while myocardial infarction, cardiac complications, and cardiac death occurred in ≤35% troponin-positive patients in four of six studies. Several noncardiac factors were associated with elevated troponin including higher American Society of Anaesthesiologists score, current smoking, reduced mobility/activity level, lower hemoglobin, and living in residential care. Patients with elevated troponin had longer lengths of stay, increased risk for discharge to long-term care facilities, and higher mortality. Increased age, male sex, and higher American Society of Anaesthesiologists score were also associated with mortality. Elevated troponin can be used as a marker of increased morbidity/mortality in elderly hip fracture patients undergoing surgery, as hypothesized, even in the absence of cardiac complications. Perioperative troponin evaluation may be useful for risk stratification, but further studies are needed to clarify risks and benefits of such testing.

The safety and efficacy of antitumour necrosis factor-alpha therapy for inflammatory bowel disease in patients post liver transplantation: a case series

BACKGROUND

The role of antitumour necrosis factor-alpha (anti-TNF) therapy for inflammatory bowel disease (IBD) among liver transplant recipients is largely unknown given the rarity of this population and the paucity of literature on the subject.

AIM

To investigate the safety and efficacy of anti-TNF therapy for refractory IBD in the post liver transplant population.

METHODS

The liver transplant database at London Health Sciences Centre was searched to identify adult patients with IBD treated with anti-TNF therapy post transplantation.

RESULTS

Six patients (five men, one woman) were identified, aged 28-65. All patients had cadaveric orthotopic liver transplants. Four patients required transplantation due to primary sclerosing cholangitis, one due to autoimmune hepatitis, and one due to biliary atresia. Five patients suffered from Crohn's disease and the remaining patient from indeterminate colitis. All patients were treated with infliximab 5 mg/kg every 8 weeks after undergoing induction at weeks 0, 2 and 6, with the exception of one patient. The duration of infliximab therapy ranged from 8 weeks to 4 years. Four patients treated with infliximab experienced sustained improvement of their IBD symptoms post transplantation, as documented by Harvey-Bradshaw Index scores demonstrating clinical remission. Of the remaining two patients, neither had sustained improvement of their IBD with infliximab or subsequent adalimumab. One patient was diagnosed with systemic lupus erythematosus and another with colorectal adenocarcinoma following anti-TNF therapy. Otherwise, no side effects were attributed to anti-TNF therapy.

CONCLUSIONS

Based on this case series, anti-TNF therapy appears to be safe and effective for treating refractory IBD in patients post liver transplantation. These patients respond to anti-TNF therapy similar to those who have not been previously transplanted.

Pulmonary artery sarcoma mimicking a pulmonary embolism

Sarcomas involving the lung are a rare occurrence, often a result of metastatic disease from primary malignancies involving the skin, liver, breast or heart. Primary pulmonary artery sarcomas are rarer still, with limited cases reported world-wide and consequently data regarding treatment modalities are sparse and largely experimental. These tumors are often mistaken for a pulmonary embolism and seemingly supported by radiological findings. Patients will often present without symptom resolution despite therapeutic anticoagulation. The following case illustrates how a soft tissue sarcoma of the pulmonary artery can mimic a pulmonary embolism, thus, resulting in both a diagnostic and therapeutic dilemma. A positron emission tomography scan was an invaluable tool in this case, showing increased radiotracer uptake and placing neoplasm at the top of the differential diagnosis. This ultimately led to a biopsy that was vimentin positive, cytokeratin negative and CD117 negative, thus consistent with soft tissue sarcoma.

Role and extent of neck dissection for persistent nodal disease following chemo-radiotherapy for locally advanced head and neck cancer: how much is enough?

PURPOSE

Neck dissection (ND) is routinely performed for persistent nodal disease after definitive chemo-radiotherapy (CRT) for locally advanced head and neck cancer. This study analyzes the role and extent of ND necessary after CRT based on pathologic outcome.

PATIENTS AND METHODS

The study is based on 42 patients undergoing 48 ND's for persistent nodal disease after CRT. Patients were treated to a median radiation dose of 70.4 Gy at 1.8-2 Gy per fraction concurrently with platinum based chemotherapy. Patients with documented residual disease in neck, based on clinical or radiological examination underwent ND at a median interval of 59 days after completion of CRT.

RESULTS

Of the 42 patients undergoing ND, 11 (26%) had positive findings on pathologic evaluation. The clinical and treatment characteristics were similar for node negative and positive patients. The involved nodal level(s) were always confined within the clinically documented persistent disease. The median percentage of positive nodes to total nodes removed was 10%. Almost 50% of positive nodes removed had only microscopic or minute viable cancer pathologically. The outcome was better for pathologically node negative patients in comparison to node positive patients.

CONCLUSION

The results of this study suggest that standard ND appears to be an excessive treatment for persistent nodal disease after CRT. Limited ND or even gross nodal resection confined to involved nodal level(s) as identified clinically or radiologically should be tested in a prospective randomized trial for reducing treatment related morbidity while maintaining excellent loco-regional control.

Voided Urinary Cytology in Bladder Cancer: Is It Time to Review the Indications?

OBJECTIVES

The sensitivity of voided urinary cytology has been reported as very low. In this study, we investigated the sensitivity and clinical utility of voided urinary cytology in the detection of various grades and stages of transitional cell carcinoma (TCC) of the bladder compared with the urinary nuclear matrix protein-22 (NMP-22) qualitative assay.

METHODS

From March 2004 to April 2006, all patients with TCC of the bladder receiving follow-up care and those presenting with gross hematuria were enrolled in this prospective study. These patients underwent urinary cytologic examination and NMP-22 qualitative assay. The diagnosis, determined from the cystoscopy findings and biopsy findings of the suspicious lesion, was accepted as the reference standard.

RESULTS

A total of 196 patients were enrolled in this study, of whom 127 patients had previously been diagnosed with bladder TCC and 69 were presenting for investigation of gross hematuria. A total of 52 cases of bladder TCC were diagnosed. The overall sensitivity of voided urine cytology and NMP-22 assay was 21.1% and 67.3%, respectively (P <0.001). The sensitivity of urinary cytology and urinary NMP-22 for well-differentiated tumors was 9.5% and 52.4%, respectively, and was 18.1% and 77.3%, respectively (P <0.001), in moderately differentiated tumors. The overall specificity of urinary cytology for TCC of the bladder was 98.6% and was greater than the specificity of NMP-22 (80.5%).

CONCLUSIONS

The results of our study suggest that urinary cytology has a very low sensitivity and can be omitted in favor of NMP-22 in the follow-up of low-grade superficial bladder TCC.

Index for measuring child feeding practices

OBJECTIVE

The present investigation was undertaken with the objective of creating an Infant and Child Feeding Index (ICFI) from a set of complementary feeding (CF) practices and to determine its association with growth of infants and young children (6-23 months).

METHODS

A semi-structured interview schedule was used to collect information for 204 children from one large slum (n=104) and two private pediatric clinics (n=100) of urban Vadodara.

RESULTS

Results revealed that about half (50.5%) of the children were stunted Ht for Age Z score (HAZ<-2SD), nearly one-fourth (25.5%) were underweight Wt for Age Z score (WAZ<-2SD), but wasting (WHZ Wt for Ht Z score<-2SD) was low (3%). Significant associations were revealed between almost all positive CF practices and nutritional status of the children as measured by HAZ and WAZ (p<0.01), but not with WHZ. Good associations were revealed between ICFI and HAZ and WAZ, but not with WHZ. On multivariate analysis of factors affecting the HAZ, WAZ and WHZ scores, ICFI was not found to be significant whereas maternal education was the most significant factor, which was also found to be associated significantly with ICFI.

CONCLUSION

It is concluded that the composite index in its present form can reflect the CF practices more holistically than just one or few behaviors studied separately. More research is needed in the direction of constituting a composite index which can then be used for research, monitoring, evaluation and much needed advocacy for complementary feeding.

Infant and child feeding index

Traditional indicators of child feeding practices are widely used and appear to be useful, although the validity and reliability of those related to complementary feeding have not been established. Composite child feeding indices have the potential to address some of the methodological constraints related to the quantitative measurement of child feeding practices. They can address the multi-dimensionality of child feeding practices i.e. the need to consider the type, quality, texture, nutrient density of food, frequency of feeding and diversity of the diet; the age-specificity of child feeding practices; and the fact that feeding practices tend to cluster. The main advantage of creating a composite index is that it allows construction of one variable representing various dimensions of feeding or care practices. This variable, in turn, can be used to illustrate graphically the importance of child feeding or care for child outcomes or to model their determinants. This can be invaluable for advocacy, apart from being an indispensable tool for the purposes of research, monitoring and evaluation. Experience with creation of composite child feeding indices with the studies in Accra and DHS data sets from Latin America and Ethiopia has been encouraging and suggests that this is a promising area for future development and program applications.