Assessing bone density on MRI: comparison between routine MRI sequences and DEXA scans

PURPOSE

Magnetic Resonance Imaging (MRI) is frequently utilised to aid in the comprehensive assessment of back pain, while dual-energy x-ray absorptiometry (DEXA) is the gold standard test for the assessment of bone density. Assessing bone density on MRI could reduce costs and avoid exposing patients to ionising radiation. The aim of this paper is to investigate whether the relative signal intensity of vertebral bodies compared to other structures can detect osteoporosis on MRI.

METHODS

100 patients that had undergone both a lumbar spine MRI and a DEXA scan were identified. The T1 and T2 signal intensity of L1-L4 vertebral bodies (VB), cerebro-spinal fluid (CSF), and psoas muscle were measured within a 1-cm2 region of interest (ROI), and the signal intensity ratios were calculated. The ratios were stratified as normal, osteopenic, or osteoporotic based on DEXA T-scores.

RESULTS

The T1 VB /T1 CSF ratio was significantly higher in the osteoporotic group than the normal and osteopenic groups (p < 0.001). The T1 VB /T1 CSF ratio had excellent discrimination (AUC = 0.841) for the presence of osteoporosis. The Pearson correlation coefficient between the DEXA T-score and the T1 VB/T1 CSF ratio was -0.474 (p < 0.001). The intra-observer (ICC = 0.910, 95% CI = 0.757-0.966) and inter-observer reliability (ICC = 0.927, 95% CI = 0.824-0.970) were excellent. In our cohort, a T1 VB / T1 CSF ratio of greater than 4 is 66.7% sensitive but 90.0% specific for the presence of osteoporosis.

CONCLUSION

A high T1 VB/T1 CSF ratio suggests osteoporosis on MRI. Prospective validation is needed to confirm these findings.

Descemet's membrane endothelial keratoplasty rejection after SARS-COV2 infection or vaccination: 2-year retrospective study

PURPOSE

To assess the incidence of Descemet's membrane endothelial keratoplasty (DMEK) rejection potentially associated with coronavirus disease 2019 (COVID-19) infection or vaccination, and its association with known rejection risk factors during the first two years of the pandemic.

METHODS

This retrospective study included patients with DMEK rejection between January 2020 and December 2021. Diagnostic criteria were based on symptoms, visual acuity, and other clinical assessments. Risk factors for graft rejection were considered, and a telephone survey was conducted to identify possible preceding COVID-19 infection or vaccination.

RESULTS

Of 58 patients, 44 were included. Six patients (14%) reported COVID-19 infection, with one immediate endothelial graft rejection (EGR) post-infection. After vaccine availability, 13 of 36 patients had EGR at an average of 2.7 months post-vaccination. Five (38%) had immediate EGR following vaccination, four of which had concomitant risk factors for rejection.

CONCLUSION

Although the risk of endothelial graft rejection (EGR) associated with COVID-19 infection or vaccination appears to be extremely low, there may be a causative relationship, especially in patients with pre-existing risk factors for EGR. A temporary increase in anti-rejection treatment following COVID-19 infection or vaccination is recommended, especially in patients with pre-existing risk factors, along with closer monitoring during the subsequent 4 to 8 weeks.

Tibiotalocalcaneal nail and primary closure for the management of open ankle fractures in the elderly patient; results from a major trauma centre

INTRODUCTION

Open ankle fractures in elderly patients are challenging injuries to manage. The aim of this study was to assess the outcome of elderly patients with open ankle fractures treated with a tibiotalocalcaneal nail and primary wound closure.

METHODS

We identified all open ankle fractures in patients over 65 referred to our major trauma centre managed with a tibiotalocalcaneal nail and primary wound closure over 10 years. We recorded patient demographics, comorbidities, injury mechanism, length of stay, operation, weightbearing status, re-operations, infections and mortality.

RESULTS

We included 34 patients with an average age of 87 (73-99). We found 56 % of patients' mobility status declined post-operatively and 21 % of patients were discharged directly home. Four patients required further unplanned surgery including two deep infections requiring amputation. We had a 6 % three month mortality rate.

CONCLUSION

Use of a tibiotalocalcaneal nail with primary wound closure offers a reasonable treatment option for open fractures of the ankle in the elderly patient.

Isolated lesions of the pubis

The osseous pelvis is a well-known area of various primary and secondary bone tumours, tumour mimics, and infections. Isolated lesions of the pubis (ILP) are rare, with few case reports in the literature. Given their sparsity, such lesions may pose a great diagnostic challenge due to varied clinical presentations and imaging features. In this study, we report the largest case series of ILP. We discuss the patient demographics, differentials, surgical approaches, and management.

Revolutionizing the effect of Azadirachta indica extracts on edema induced changes in C-reactive protein and interleukin-6 in albino rats: in silico and in vivo approach

OBJECTIVE

The aim of the present study is to determine the in vivo and in silico anti-inflammatory effect of Azadirachta indica (A. indica) in carrageenan-induced rats and its blood biomarkers. A. indica (Neem) is a widely used medicinal plant across the world, especially in Pakistan. Neem leaves have been traditionally used for the synthesis of drugs and treatment of a wide variety of diseases.

MATERIALS AND METHODS

In this study, sixty albino rats (160-200 g) were divided into 4 groups: control (group I), standard (group II), ethanolic and aqueous (group III and IV) at doses of 50, 100, 200 and 400 mg/kg.

RESULTS

Ethanolic and aqueous extracts showed maximum inhibition in paw size at the 5th hour (400 mg/kg). Similarly, biomarkers measured, including Interleukin-6 and C-reactive protein, exhibited significant anti-inflammatory activity at the highest dose of 400 mg/kg in both experimental groups but were more distinct in the group treated with ethanolic extracts. Correlation between C-reactive protein (CRP) and inter-leukin-6 (IL-6) showed positive correlation in group III, while negative in group IV. Similarly, positive and negative correlations were observed between CRP biomarkers and paw size in group III and IV, and the same results were also shown in the case of IL-6 and paw size. In molecular docking, the binding energy value of protein CRP and IL-1β with the identified ligands quercetin and nimbosterol showed (-8.2 kcal/mol and -7.7 kcal/mol) the best binding affinity as compared to standard drug diclofenac with -7.0 kcal/mol binding energy respectively.

CONCLUSIONS

In conclusion, in silico and in vivo analysis revealed that the extracts of A. indica leaves can be used as an effective drug to manage inflammation.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

The efficacy of Zafirlukast as a SARS-CoV-2 helicase inhibitor in adult patients with moderate COVID-19 Pneumonia (pilot randomized clinical trial)

OBJECTIVE

To assess the efficacy of Zafirlukast as a SARS-CoV-2 Helicase Inhibitor in adult patients with moderate COVID-19 symptoms (hospitalized patients with COVID-19 pneumonia who were not admitted to an intensive care unit).

METHODS

We conducted a randomized, double blind, placebo-controlled, pilot trial with adult patients with moderate COVID-19 pneumonia. The sample was randomized to Zafirlukast 10 mg BD for 10 days plus standard care vs placebo plus standard care. The primary outcome was the complete resolution of all symptoms. The secondary outcomes were the duration of oxygen therapy, and length of hospital stay (LOS).

RESULTS

In total, 40 patients were randomized (20 to Zafirlukast and 20 to the control). The time to the resolution of clinical symptoms in both groups was not significantly different. Regarding the fever, 0.3 days [95 % CI, - 1.19, 0.69], p = 0.76, for shortness of breath, the difference was 0.4 days [95 % CI, - 2.67, 3.46], p = 0.68, for cough the difference was 0.2 days [95 % CI, - 1.45, 1.95], p = 0.98, for sputum the difference was 0.5 days [95 % CI, - 0.75, 1.85], p = 0.09, for vomiting the difference was 0.1 days [95 % CI, - 0.50, 0.30], p = 0.93, for fatigue the difference was 0.3 days [95 % CI, - 4.32, 3.62], p = 0.64. The LOS per day for the two groups was not significantly different, 1.1 days [95 % CI,- 2.03, 4.28], p = 0.94, nor was the duration of oxygen therapy per days, 1.3 days [95 % CI, - 1.79, 4.49], p = 0.49. Regarding the 7 category ordinary scale, there was no significant difference between the two groups at day 7 (p-value = 0.62), day 14 (p-value = 0.60) and day 28 (p-value = 0.48).

CONCLUSION

Among adult patients hospitalized with COVID-19 pneumonia, the treatment with Zafirlukast, compared to placebo, did not significantly improve symptoms resolution.

775 Role of Inversion Imaging in the Diagnoses of Neck of Femur Fractures

Aim

The objective of this study was to assess whether inversion of grey scale radiograph images has any impact on the diagnostic sensitivity and inter-observer reliability in diagnosing neck of femur fractures.

Method

We performed a retrospective, single centre study, using 50 randomly selected AP pelvis radiographs. The images included a combination of normal, intracapsular and extracapsular neck of femur fractures, which had been confirmed on CT, MRI and/or subsequent surgery.

Four independent observers (two orthopaedic specialists, one registrar and one SHO in orthopaedics) reviewed the images and graded each radiograph image using the Likert scale in response to the statement “there is a fracture”. Following this, the same radiographs were inverted to grey scale images and sent for a second review using the same method. RAND correlation was used for statistical analysis.

Results

Overall, observers appeared to have similar accuracy and equivocal rates with normal and inversion radiographic imaging.

One of the T&O Consultant's had much higher equivocal rate when analysing inverted radiographs compared to conventional digital radiographs but had slightly higher accuracy with inversion (95.35% compared to 93.88%) as well as the Registrar (83.33% compared to 81.63%). The second Trauma and Orthopaedics Consultant had slightly more accuracy with conventional digital radiographs (89.58% compared with 87.50%).

Conclusions

Inversion of digital radiographs did not affect the diagnostic sensitivity of neck of femur fractures in our study, and similarly did to not have a statistically significant impact in clinician confidence in diagnosing neck of femur fractures.

The Linear Hallux Valgus Offset- A novel way to measure Hallux Valgus

INTRODUCTION

Hallux Valgus (HV) is a complex deformity involving the first ray of the forefoot and a common cause of forefoot pain. Several radiological measurements such as Hallux Valgus Angle (HVA), First Metatarsophalangeal Angle (IMA) and Distal metatarsal articular angle (DMAA) exist to calculate the severity of HV and direct patient management. However, these are angular measurements are prone to error with variable intra- and inter-observer reliability.

PURPOSE

To describe a new radiological linear hallux valgus offset (LHVO) to measure HV deformity.

PATIENT AND METHODS

We performed a retrospective cohort study looking at Antero-posterior, weight-bearing foot radiographs of 100 consecutive patients with forefoot pain referred to our foot and ankle clinic. Demographic details, clinical indication, HVA (hallux valgus angle) and LHVO were measured for each patient and data were analyzed using the student t-test. Intraclass Correlation Coefficient (ICC) analysis was evaluated to assess the intra-class reliability between observers.

RESULTS

There was a female predominance of approximately 2:1, with 51.3 years (range 13-86 years). There was a statistically significant difference of LHVO between normal and hallux valgus cohorts with a p-value of 0.0001. The LHVO gave moderate intra-observer and inter-observer reliability on ICC analysis of 0.7.

CONCLUSION

The LHVO can be an additional measure of assessing severity of hallux valgus. In contrary to the traditional angular measurements, this linear measure is easier to calculate and reproducible on plain, weight bearing radiographs. LHVO measurement has shown a moderate inter-observer reliability in the study to complement traditional radiological evaluation of hallux valgus alignment.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Tumors of the Acromion Process—A Pictorial Review

Introduction  Acromion is essential for stabilizing the shoulder complex. Tumors of the acromion are rare. We report the largest series of acromion tumor and tumor-like lesion.

Materials and Methods  A retrospective review of the oncology and radiology database within our tertiary center for orthopaedic oncology was performed to identify all tumors of the acromion over the past 30 years and imaging was reviewed.

Results  We identified a total of 31 lesions arising in the acromion and chondrosarcoma was the commonest.

Conclusion  One needs to be aware of tumor and tumor-like lesions of acromion.

Late Clinical and Hemodynamic Outcomes in patients with degenerated bioprosthetic aortic valves undergoing transcatheter valve-in-valve implantation

Background

Clinical studies have shown promising early outcomes for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI); however, the late outcomes of this procedure remain under-investigated.

Purpose

We performed the present analysis to assess the late clinical and hemodynamic outcomes of ViV-TAVI in patients with degenerated bioprosthetic aortic valves.

Methods

A comprehensive chart review was performed for eligible patients to retrieve data on procedural characteristics, admission details following the procedure, and echocardiographic parameters. Clinical outcomes included all-cause mortality, heart failure hospitalization and structural valve deterioration (SVD), as defined by VARC-II criteria, up to 5 years of follow-up. To assess the trends in mean and peak transvalvular gradients, data from the follow-up echocardiographic reports were analyzed using Syngo Dynamics imaging software.

Results

A total of 188 patients were included with a mean age of 75.8±10.4 years. Balloon- and self-expandable valves were used in 155 (82.4%) and 33 (17.6%) patients, respectively. At 30 days, 3 (1.6%) patients died and 8 (4.2%) required hospitalization for heart failure, while at 5 years, both events were recorded in 29 (15.4%) and 37 (19.7) patients, respectively. Kaplan-Meier survival analysis showed that patients with smaller surgical valves (internal diameter ≤21 mm) had a significantly higher mortality rate (log-rank p=0.021) than those with larger valves; however, no significant difference (log-rank p=0.59) was detected between different transcatheter valves (self vs. balloon-expandable). Three patients underwent re-intervention, performed via a transcatheter approach. Further, assessment of follow-up echocardiographic reports revealed 9 (4.8%) cases of SVD, as well as stable mean (16.3±6.9 at discharge and 16.9±11.3) and peak (30.3±12.1 at discharge and 30.7±18.4 at 5 years) transvalvular gradients. No difference (p&gt;0.05) was observed based on transcatheter valve type or surgical valve internal diameter in terms of mean and peak transvalvular gradients throughout the follow-up period.

Conclusion

The present study showed good clinical outcomes among patients undergoing VIV-TAVI, with stable VIV performance over a five-year period. Future long-term studies are warranted to analyze the predictors of outcomes following ViV-TAVI and explore the role of this treatment option in the life-long management of aortic stenosis.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jennifer and Robert McNeil Donation to the Heart, Thoracic, and Vascular Institute at Cleveland Clinic. Figure 1

Evidence in crisis: a closer look into the quality of published systematic reviews in the cardiology literature

Background

Systematic reviews are usually considered as the highest level of evidence and are increasingly used in shaping cardiology policies and guidelines. However, as the rate of publishing systematic reviews increases annually, there are rising concerns regarding their quality and reporting standards.

Purpose

The current analysis provides an insight into the quality of published systematic reviews in cardiology and provides recommendations for researchers, clinicians, and stakeholders in this regard.

Methods

Using a comprehensive Medline/PubMed search, we retrieved all systematic reviews, published between 2009 and 2019 in five general cardiology journals with the highest impact factor as per the Clarivate Analytics 2019 Journal Impact Factor List (Circulation, European Heart Journal, Journal of the American College of Cardiology, Circulation Research, and JAMA Cardiology). We assessed the methodological characteristics, eligibility criteria, reporting standards, as well as review quality scores according to the AMSTAR tool.

Results

Among 352 retrieved reviews, 275 (75.3%) performed direct head-to-head analysis and 164 (46.6%) included only clinical trials. The median numbers of searched databases and included studies were 3 (IQR: 2, 3) and 13 (IQR: 7, 30). The primary outcomes were often hard clinical endpoints as mortality (39.2%) and stroke (11.9%). 64 (18.2%) registered their protocol, 208 (58.4%) used validated tools for risk of bias assessment, 177 (52.3%) assessed for publication bias, and 221 (62.8%) adhered to the PRISMA checklist. Thirty-five reviews detected significant publication bias, which was significantly associated with heterogeneity of the primary outcome. The AMSTAR quality scores were low or critically low in 71% of evaluated reviews. Further, 87 (24.7%) did not report on whether they received funding or not, 33 (9.4%) reported receiving no funding, and 232 adequately reported on their funding sources [70 (19.9%) from governmental/academic sources, 120 (34.1%) from pharmaceutical companies, and 42 (11.9%) from both sources]. analysis showed that reviews with advanced statistical analysis, those that included RCTs, adhered to the PRISMA checklist, or had higher AMSTAR quality scores had significantly higher citation metrics (p&lt;0.05).

Conclusion

Due to the widespread low quality and poor reporting in cardiovascular systematic reviews, clinicians should be educated on the value of methodological quality in interpreting systematic review findings. In addition, academic societies and guideline writing groups should implement rigorous critical appraisal and peer review policies to improve the synthesis and utilization of systematic reviews in evidence-based cardiovascular medicine.

Funding Acknowledgement

Type of funding sources: None.

The incidence and management of Isolated Greater Trochanteric Fractures - A systematic review of 166 cases

BACKGROUND

Isolated fractures of the greater trochanter are unusual injuries with a wide spectrum of presentation, investigations and management strategies.

AIMS

The objective of this study was to evaluate the incidence and treatment protocols used in the management of Isolated Greater Trochanteric Fractures (IGTF).

METHODS

A systematic literature review of the PubMed and Central Register of Controlled Trials (Cochrane) databases by using the search term 'greater trochanter fracture and hip fracture' was conducted for Randomised Controlled Trials (RCT's), including prospective and retrospective non-experimental studies.

RESULTS

The search yielded 15 studies meeting our inclusion criteria encompassing 166 patients with Isolated Greater Trochanteric Fractures (IGTF). Most of the reports were observational studies due to paucity of coverage on this topic in literature. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) were the common modalities used to diagnose these injuries. Most of the patients were managed with non-operative methods.

CONCLUSION

This systematic review analyses the consensus of treatment of IGTF based on evidence-based practice. When the IGTF is identified, the majority of studies advocate conservative management to surgery for such cases. Furthermore, large cohort studies with clearly documented outcome follow up are required to establish objective treatment guidelines for IGTF.

Myositis ossificans revisited - The largest reported case series

INTRODUCTION

Myositis ossificans (MO) is a condition characterised by the formation of non-neoplastic heterotropic ossification in extraskeletal soft tissues.

MATERIAL AND METHODS

We performed a retrospective study of our radiology databases within our tertiary orthopaedic centre to identify all cases of MO, reported on X ray, Magnetic resonance imaging (MRI) and Computed tomography (CT) over the past 13 years (2007-2020).

RESULTS

We identified 68 cases of MO, which were included into our cohort. The average age of our patients was 36 years (range 4-84 years). 73% of cases (n = 50) were found to affect the lower limb muscles with the majority in the quadriceps.

CONCLUSION

We report the largest case series of MO and discuss the demographics, diagnoses and management.

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19

Background

Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear.

Objectives

The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre–COVID-19 cohorts.

Methods

From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019).

Results

In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).

Conclusions

In this multicenter international registry, COVID-19–positive ACS patients presented later and had increased in-hospital mortality compared with a pre–COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.

155 Audit of Functional Outcome of Mason and Molloy Type 2 Posterior Malleolar Ankle Fractures Treated with Open Reduction and Internal Fixation Using A Posterolateral Approach

Introduction

It has been shown that direct fixation of the posterior malleolus improves functional outcomes. Our aim was to audit the functional outcome of patients with these fractures which were fixed with an isolated posterolateral approach.

Method

A consecutive case series of patients who underwent direct fixation of the posterior malleolus using a posterolateral approach between 20/12/2012 and 23/1/2020 was identified. Fractures were classified according to Mason and Molloy classification based on preoperative CT. Type 2a and 2b fractures were included. Functional outcome was assessed using Olerud-Molander score.

Result

18 patients were included. Mean age at time of surgery was 52 years (range 20 to 75 years). 56% (n = 10) were female. Mean follow up was 18.1 months (range 4.2 months to 7.2 years). OMAS score for type 2a fractures (n = 9) was 71.1 (95% CI 65.3 to 77.0). OMAS score for type 2b fractures (n = 9) was 67.8 (95% CI 54.6 to 81.0). There was no significant difference between groups (p = 0.65).

Conclusions

Fixation of Mason and Molloy Type 2 fractures using an isolated posterolateral approach results in satisfactory functional results for the majority of patients. Further prospective comparative study is needed to identify which patients benefit most from alternative approaches.

Prospective follow-up in various subtypes of cardiomyopathies: insights from the ESC EORP Cardiomyopathy Registry

AIMS

The European Society of Cardiology (ESC) European Observational Research Programme (EORP) Cardiomyopathy Registry is a prospective multinational registry of consecutive patients with cardiomyopathies. The objective of this report is to describe the short-term outcomes of adult patients (≥18 years old).

METHODS AND RESULTS

Out of 3208 patients recruited, follow-up data at 1 year were obtained in 2713 patients (84.6%) [1420 with hypertrophic (HCM); 1105 dilated (DCM); 128 arrhythmogenic right ventricular (ARVC); and 60 restrictive (RCM) cardiomyopathies]. Improvement of symptoms (dyspnoea, chest pain, and palpitations) was globally observed over time (P < 0.05 for each). Additional invasive procedures were performed: prophylactic implantation of implantable cardioverter-defibrillator (ICD) (5.2%), pacemaker (1.2%), heart transplant (1.1%), ablation for atrial or ventricular arrhythmia (0.5% and 0.1%). Patients with atrial fibrillation increased from 28.7% to 32.2% of the cohort. Ventricular arrhythmias (VF/ventricular tachycardias) in ICD carriers (primary prevention) at 1 year were more frequent in ARVC, then in DCM, HCM, and RCM (10.3%, 8.2%, 7.5%, and 0%, respectively). Major cardiovascular events (MACE) occurred in 29.3% of RCM, 10.5% of DCM, 5.3% of HCM, and 3.9% of ARVC (P < 0.001). MACE were more frequent in index patients compared to relatives (10.8% vs. 4.4%, P < 0.001), more frequent in East Europe centres (13.1%) and least common in South Europe (5.3%) (P < 0.001). Subtype of cardiomyopathy, geographical region, and proband were predictors of MACE on multivariable analysis.

CONCLUSIONS

Despite symptomatic improvement, patients with cardiomyopathies remain prone to major clinical events in the short term. Outcomes were different not only according to cardiomyopathy subtypes but also in relatives vs. index patients, and according to European regions.

ESC EORP Cardiomyopathy Registry: real-life practice of genetic counselling and testing in adult cardiomyopathy patients

Aims

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin. We assessed the current practice of genetic counselling and testing in the prospective European Society of Cardiology EURObservational Research Programme Cardiomyopathy Registry.

Methods and results

A total of 3208 adult patients from 69 centres in 18 countries were enrolled. Genetic counselling was performed in 60.8% of all patients [75.4% in hypertrophic cardiomyopathy (HCM), 39.2% in dilated cardiomyopathy (DCM), 70.8% in arrhythmogenic right ventricular cardiomyopathy (ARVC), and 49.2% in restrictive cardiomyopathy (RCM), P < 0.001]. Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (P < 0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%) (P < 0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% in ARVC, and 43.6% in RCM, P < 0.001). Index patients with genetic testing were younger at diagnosis and had more familial disease, family history of sudden cardiac death, or implanted cardioverter defibrillators but less co‐morbidities than those not tested (P < 0.001 for each comparison). At least one disease‐causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC, and 42.9% in RCM, P = 0.13).

Conclusions

This is the first detailed report on the real‐life practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

AB0956 VERTICAL NAIL RIDGING IN PATIENTS WITH FIBROMYALGIA: FREQUENCY, PROPOSED GRADING AND CORRELATION WITH OTHER DISEASE FEATURES

Background:

The vertical nail ridging (VNR) has long been reported to be related to stressful conditions1

Objectives:

to evaluate the frequency of VNS in FM patients and its relation to other disease parameters depending on a proposed grading.

Methods:

VNR has been searched for in 212 FM patients (2016 criteria). The number of fingers, the degree of VNR according to this proposed grading (0: no ridging, 1: ridging only detected by a magnifying lens, 2: ridging seen by naked eye and 3: ridging that can be seen and felt) and other FM features according to the new and old ACR criteria have been recorded. 80 subjects of those consulting for knee osteoarthritis have been examined for VNR and those found positive were asked about the FM features and examined for tender points. Patients aged >50 years and those with psoriasis and fungal infections were excluded.

Results:

the mean age of patients was 32.4±9.9 (73.6% were female). The mean disease duration was 5.8±3.7, while the means of WPI, SSS and tender points were 9.4±2.9, 7.3±1.2 and 14.7±2.3 respectively. VNR was found in 209 patients (98.6%). Of 80 controls, VNR has been found in 61 subjects, of whom FM has been diagnosed in 32 patients (52.4%) by 2016 FM criteria and in 46 (75.4%) by 1990 criteria. The number of fingers with VNR has been found only correlated with the disease duration (r= 0.276, P = 0.000). The severity of VNR was significantly correlating with fatigue (P= 0.002), sleep disturbance (P= 0.001), awaking unrefreshed (P = 0.000), WPI (p = 0.01) and mean tender points (P =0.02). Considering the 2016 criteria as a gold standard, the sensitivity of VNR was 98.37%, the specificity was 9.68% and the diagnostic accuracy was 82.8%.

Conclusion:

vertical nail ridging is a frequent finding and can be considered helpful for diagnosis of patients with FM. Further studies are needed to validate this sign for diagnosis and follow up of FM patients.

References:

[1]American Academy of Dermatology. (2007, November 12). Feeling Stressed? How Your Skin, Hair And Nails Can Show It.Science Daily. Retrieved December 30, 2019 fromwww.sciencedaily.com/releases/2007/11/071109194053.htm

Disclosure of Interests:

None declared

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Anterior translation of the tibia in relation to femur in mucoid degeneration of ACL - An observational study

Background

Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) are a well-known pathological entity.We have encountered several patients with MD of the ACL, found to have a anterior translation of tibia a exceeding 5 mm with an intact ACL. We studied this cohort and investigated the likely cause of this.

Methods

A retrospective search of our department's radiology system to identify all patients referred from the knee orthopaedic clinic for MR imaging over a span of 10 years. All patients had MD within the substance of the ACL and an intact ACL. We evaluated the degree of anterior translation of the tibia (ATT) in relation to the femur in mucoid degeneration of ACL.

Results

We identified 464 consecutive cases. The mean age was 52 years. There was a male predominance of 261 to 203 female. The average PTF measurement was 2.4 mm with a range of 0-20mm. Of the 464 cases, 3 397 patients had an insignificant ATT of < 5 mm. (0mm. 67. 67 67 patients had a ATT >5 mm. Of them, 32.8% had a ATT of 6 mm, 53.7% had a ATT range between 7 and 9 mm, with the remaining 13.4% above 9 mm in length.

Conclusion

It is essential to look for other secondary signs of ACL tears and not only focus on ATT as well as correlate this with clinical findings.

P971 The echocardiographic phenotype in patients with cardiac amyloidosis and heart failure with preserved ejection fraction

BACKGROUND

New echocardiographic phenotypes of heart failure (HF) are focused on myocardial systolic involvement of the left ventricle (LV), either endocardial and/or transmural.

PURPOSE.

To study the pattern of myocardial involvement in patients (p) with HF with preserved left ventricular ejection fraction (pLVEF) and cardiac amyloidosis (CA).

METHODS.

Comparative study of 16 p with CA and HF with pLVEF, considering as cut point LVEF &gt; 50%, in NYHA class ≥ II / IV, and a control group of 16 healthy people. Longitudinal Strain (LS) and Circumferential Strain (CS) were calculated using 2D speckle-tracking echocardiography, along with Mitral Annulus Plane Systolic Excursion (MAPSE) and Base-Apex distance (B-A). Also, the following indexes were calculated: Twist (apical rotation + basal rotation, º); Classic Torsion (TorC): (twist/B-A, º/cm); Torsion Index (Tor.I): (twist/MAPSE, º/cm) and Deformation Index (Def.I): (twist/LS, º).

We suggest the introduction of these dynamic torsion indexes as Tor.I and Def.I that include twist per unit of longitudinal systolic shortening of the LV instead of using TorC which is the normalisation of twist to the end-diastolic longitudinal diameter of the LV.

RESULTS

There were no differences of age between the groups (68.2 ± 11.5 vs 63.7 ± 2.8 years, p = 0.14). Global values of LS and CS were lower in p with CA indicating endocardial and transmural deterioration during systole, while TorC and Twist of the LV remained conserved in p with CA.

However, there is an increase of dynamic torsion parameters such as Tor.I and Def.I that show an increased Twist per unit of longitudinal shortening of the LV in the CA group (Table).

CONCLUSIONS

In p with CA and HF with pLVEF, the impairment of LS and CS indicates endocardial and transmural systolic dysfunction. In these conditions, LVEF would be preserved at the expense of a greater dynamic torsion of the LV.

Table LS (%) CS (%) Twist (º) TorC (º/cm) Tor.I (º/cm) Def.I (º/%) CA pLVEF (n = 16) -11.7 ± 4.2 17.2 ± 4.8 19.8 ± 8.3 2.5 ± 1.1 27.7 ± 13.5 -1.8 ± 0.9 Control Group (n = 15) -20.6 ± 2.5 22.7 ± 4.9 21.7 ± 6.1 2.7 ± 0.8 16.4 ± 4.7 -1.0 ± 0.3 p &lt; 0.001 &lt; 0.01 0.46 0.46 &lt; 0.01 &lt; 0.01 Dynamic Torsion Indexes and Classic Torion Parameters in pLVEF CA patients vs Control group.

P1402 The behavior of regional longitudinal strain depends on the coronary reserve in a simultaneous analysis during Dipyridamol Stress Echocardiography Test

Objectives

Compare the behavior of the Apical LS and GLS with the value of the CFR in the LADA and as a secondary objective to compare these responses with a simultaneous visual analysis of the motility during EchoDipi.

Materials and methods

179 patients (p) were included (age 68.7 ± 7 years). Of them, 113p(65%) were men. At the peak of the effect of Dipi(0.84mg/kg in 4m) the CFR was measured in the distal region of the LADA(Normal Value≥2). The subjects were divided into 2 groups(G): G1: p with CFR of the LAD≥2 and G2 p with LADA CFR &lt; 2. ApRLS was defined as the average of the 4 apical segments, in 4, 3 and 2 apical views, considering any increase in the percentage of deformation as normal. The LGS and wall motility of the 17 segments were evaluated; p with LBBB or wall motion abnormalities were excluded.

Results

Of 179 p, 113p(63.12%) were included in G1 and 66p(36.87%) in G2. G1 were older(65.9 ± 10.27 vs 72.2 ± 9.31,p &lt; 0.02), without significant differences in other clinical characteristics. No differences in the values of LGS and the Ap RLS at rest between G1 and G2 (GLS: G1: -19.8 ± 4.8 vs G2: -20.27 ± 2.6 p = NS; Ap RLS G1: -25.41 ± 4.75 vs G2: -26.73 ± 7.6 p = NS). During EchoDipi GLS and Ap RLS increased in the pts of G1 with a significant worsening in the G2 (SLG: G1: -22.98 ± 4.31 vs G2: -17.82 ± 2.70, p &lt; 0.0001; Ap SLR G1: -28.43 ± 5.6 vs. G2: -22.78 ± 7.41, p &lt; 0.0001). We observed that in 96.7% of p G1 the ApRLS increased strain with the stress meanwhile 95.31% of the G2 decrease(p &lt; 0.0001). Negative predictive value (NPV) :95.6%(CI = 87.8-98.5%), positive predictive value (PPV) =96.8%(CI = 89.0-99.1%).Specificity(E): 97%(CI = 89.9-99.2%),Sensibility(S): 95.2%(CI = 86.9-98.4%). Area Under the ROC curve(AUC)=0.92. The behavior of the GLS showed that 82.8% of the pts of the G1 during EchoDipi increased their Strain values in contrast with 78.8% p of the G2 decrease p &lt; 0.01).NPV 78.8%(CI = 67.5-86.9%),PPV:90.8%(CI = 83.9-94.9%),E:83.9% (CI = 72.8-91.0%),S:87.6%(CI = 80.3-92.5%).AUC ROC= 0.84. The analysis of wall motility showed that 96.46%(109p) of G1 had preserved wall motility, 1 p showed contractility abnormalities and decreased ApRLS. Of the G2, 36p showed conserved contractility during the stress.

Conclusions.There was a close correlation between LADA coronary flow reserve and the contractile reserve evaluated by regional longitudinal strain of the 4 apical segments, which was superior to the use of global longitudinal strain. The Apical Strain showed a better correlation with the LADA coronary flow reserve than with the visual analysis of wall motion.

P308 Changes in the echocardiographic phenotype during the evolution of cardiac amyloidosis from preserved to reduced left ventricle ejection fraction

Introduction

Cardiomyopaties like Cardiac Amyloidosis (CA), are an important cause of Heart Failure (HF). They can cause endocardial or transmural involvement. It is possible to characterize the kind of affectation thanks to different phenotypes identified by 2D speckle tracking echocardiography. Purpose: To study the pattern of myocardial involvement in patients (p) affected by CA and HF. Methods: Comparative study of 30 p with CA and HF, in NYHA class ≥II/IV, of which 16 had preseved left ventricle ejection fraction (pLVEF) and 14 had reduced LVEF (rLVEF), considering as cut point a LVEF &gt; 50%. There was a control group (CG) of 16 healthy subjects. Twist, radial strain (RS), circunferential strain (CS) and longitudinal strain (LS) were determined using 2D speckle-tracking echocardiography, along with mitral annulus plane systolic excursion (MAPSE) and basal-apex distance (B-A). The following indexes were calculated: Twist (apical rotation + basal rotation, °); Torsion (twist/B-A, °/cm); Torsion Index (TorI: twist/MAPSE, °/cm), and Deformation Index (DefI:twist/LS,°). The last indexes are dynamic parameters that allow for a more realistic assessment of LV torsion, since they include longitudinal shortening measures such as MAPSE and LS, describing in a more complete and physiological way the global LV systolic movement.

Results

There were differences of age between the three gropus, being older the p with rLVEF and younger the ones in the CG (63,7 ± 2,8; 68,2 ± 11,5; y 73,9 ± 12,9 years respectively). LS and CS were lower in rLVEF group when compared with pLVEF group, as well as in pLVEF group compared with the CG. The p with pLVEF showed increased values of the dynamic torsion parameters (DefI and TorI), indicating a compensatory increase of LV twist that disappears in p with rLVEF. Twist and Torsion are significantly lower only in the rLVEF group (see table).

Conclusions

In both CA groups, LS and CS deterioration indicates endocardial and transmural involvement. The loss of compensation given by the increased LV twist, reflected by DefI and TorI, marks the transition to the deterioration of LVEF.

Results Table LVEF (%) LS (%) CS (%) TWIST (°) Torsion (°/cm) TorI (°/cm) DefI (°/%) Control Group (n = 15) 68.2 ± 6.3 -20.6 ± 2.5 -22.7 ± 4.9 21.7 ± 6.1 2.7± 0.8 16.4 ± 4.7 -1.0 ± 0.3 CA pLVEF (n = 16) 60,6 ± 5.4* -11.7 ± 4.2* -17.2 ± 4.8* 19.8 ± 8.3 2.5± 1.1 27.7 ±13.5* -1.8 ± 0.9* CA rLVEF (n = 14) 37.2 ± 8.8** -8.7 ± 3.2** -13.0 ± 3.4** 8.3 ± 5.6** 1.0 ± 1.7** 13.4 ± 9.6** -1.0 ± 0.7** *:p value &lt;0,01 between CG and pLVEF group; **:p value &lt;0,01 between pLVEF and rLVEF

From Four-Way Linking to a One Health Platform in Egypt: institutionalisation of a multidisciplinary and multisectoral One Health system

The convergence of humans, animals and our shared environment results in a dynamic in which the health of each group is inextricably linked. Taking into account the fact that the majority of emerging pathogens (e.g. highly pathogenic avian influenza [HPAI], severe acute respiratory syndrome coronavirus, Nipah virus, Middle East respiratory syndrome coronavirus) are zoonotic diseases, Egypt has established a national One Health coordination mechanism. The primary purpose of this mechanism is to provide a comprehensive, strategic approach to concurrent and future health challenges that are facing public and animal heath, including environmental impacts. In this way, the public health, animal health and environment sectors can improve disease mitigation measures, develop stronger and more stable public and animal health services, promote effective national communication strategies and improve One Health collaboration among all relevant sectors. In Egypt, the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) currently assist in hosting the country's Four-Way Linking Task Force with the participation of the convening Ministries (Ministry of Health and Population, Ministry of Environment, and Ministry of Agriculture and Land Reclamation [MOALR] - through the General Organisation for Veterinary Services and the MOALR's laboratories). In the context of the Emerging Pandemic Threats 2 Program, funded by the United States Agency for International Development (USAID), FAO plans to assist Egypt in establishing a robust, multidisciplinary and multisectoral One Health system. This system is based on the solid foundation of the Four-Way Linking Platform, which combines information from four functional streams - epidemiology, laboratories, and animal and human health. Egypt's platform will involve all sectors concerned with HPAI control and combine all stakeholders in an integrated, holistic approach to improve the detection of, response to and control of any threats at the human- animal-environment interface in Egypt.

Urinary mitochondrial DNA copy number identifies renal mitochondrial injury in renovascular hypertensive patients undergoing renal revascularization: A Pilot Study

AIMS

Patients with renovascular hypertension (RVH) exhibit elevated urinary mtDNA copy numbers, considered to constitute surrogate markers of renal mitochondrial injury. The modest success of percutaneous transluminal renal angioplasty (PTRA) in restoring renal function in RVH has been postulated to be partly attributable to acute reperfusion injury. We hypothesized that mitoprotection during revascularization would ameliorate PTRA-induced renal mitochondrial injury, reflected in elevated urinary mtDNA copy numbers and improve blood pressure and functional outcomes 3 months later.

METHODS

We prospectively measured urinary copy number of the mtDNA genes COX3 and ND1 using qPCR in RVH patients before and 24 hrs after PTRA, performed during IV infusion of vehicle (n = 8) or the mitoprotective drug elamipretide (ELAM, 0.05 mg/kg/h, n = 6). Five healthy volunteers (HV) served as controls. Urinary mtDNA levels were also assessed in RVH and normal pigs (n = 7 each), in which renal mitochondrial structure and density were studied ex-vivo.

RESULTS

Baseline urinary mtDNA levels were elevated in all RVH patients vs HV and directly correlated with serum creatinine levels. An increase in urinary mtDNA 24 hours after PTRA was blunted in PTRA+ELAM vs PTRA+Placebo. Furthermore, 3-months after PTRA, systolic blood pressure decreased and estimated glomerular filtration rate increased only in ELAM-treated subjects. In RVH pigs, mitochondrial damage was observed using electron microscopy in tubular cells and elevated urinary mtDNA levels correlated inversely with renal mitochondrial density.

CONCLUSIONS

PTRA leads to an acute rise in urinary mtDNA, reflecting renal mitochondrial injury that in turn inhibits renal recovery. Mitoprotection might minimize PTRA-associated mitochondrial injury and improve renal outcomes after revascularization.

WITHDRAWN: Effect of He-Ne laser irradiation on embryonic development in chicken eggs

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). These articles are retracted at the request of the authors. The joint Editors-in-Chief agree with this decision.