Relationship Between Caffeine Consumption and Young Athletes' Comorbidities, Exercise-Related Symptoms, and Baseline Electrocardiogram

BACKGROUND

Caffeine consumption causes diverse physiologic effects that can affect athletes both positively and negatively. There is a lack of research investigating the long-term effects of caffeine intake on exercise and on overall cardiovascular health in young athletes.

HYPOTHESIS

Certain characteristics such as age, body mass index (BMI), race, and medical diagnoses are associated with increased caffeine use, and there is a relationship between caffeine consumption and symptoms during exercise and cardiovascular abnormalities in young athletes.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

This study utilized the HeartBytes National Youth Cardiac Registry to collect data related to demographics, caffeine use, and physical examination and electrocardiogram (ECG) findings of 7425 12- to 20-year-olds (60.6% male, 39.4% female) who attended a Simon's Heart cardiac screening event between 2014 and 2021. Univariable and multivariable logistic regression models were used for analysis.

RESULTS

Persons who consumed caffeine were more likely to have attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio [aOR], 1.43; CI, 1.15-1.76]; P < 0.01) and more likely to have a BMI ≥30 kg/m2 (aOR, 1.69; CI, 1.27-2.25]; P < 0.01) compared with nondrinkers. After controlling for age, gender, race, and BMI, there were no significant differences in symptoms during exercise (aOR, 1.27; CI, 0.97-1.66; P = 0.08) or abnormal ECG findings (OR, 0.93; CI, 0.66-1.31; P = 0.70) between those who consume caffeine and those who do not.

CONCLUSION

Caffeine consumption was associated with increased BMI and increased likelihood of having ADHD; however, caffeine use overall was not associated with increased risk of symptoms during exercise or ECG abnormalities.

CLINICAL RELEVANCE

Whereas caffeine consumption overall did not increase risk of exercise-related symptoms, soda drinkers were at higher risk for symptoms during exercise, and coffee drinkers were at higher risk of syncope with exercise. Prospective studies with longitudinal follow-up and more specific outcomes data is the next step in qualifying the impact of caffeine on young athletes.

Association between number of vasopressors and mortality in COVID-19 patients

Study objective

Study the clinical outcomes associated with the number of concomitant vasopressors used in critically ill COVID-19 patients.

Design

A single-center retrospective cohort study was conducted on patients admitted with COVID-19 to the intensive care unit (ICU) between March and October 2020.

Setting

Rush University Medical Center, United States.

Participants

Adult patients at least 18 years old with COVID-19 with continuous infusion of any vasopressors were included.

Main outcome measures

60-day mortality in COVID-19 patients by the number of concurrent vasopressors received.

Results

A total of 637 patients met our inclusion criteria, of whom 338 (53.1 %) required the support of at least one vasopressor. When compared to patients with no vasopressor requirement, those who required 1 vasopressor (V1) (adjusted odds ratio [aOR] 3.27, 95 % confidence interval (CI) 1.86-5.79, p < 0.01) (n = 137), 2 vasopressors (V2) (aOR 4.71, 95 % CI 2.54-8.77, p < 0.01) (n = 86), 3 vasopressors (V3) (aOR 26.2, 95 % CI 13.35-53.74 p < 0.01) (n = 74), and 4 or 5 vasopressors(V4-5) (aOR 106.38, 95 % CI 39.17-349.93, p < 0.01) (n = 41) were at increased risk of 60-day mortality. In-hospital mortality for patients who received no vasopressors was 6.7 %, 22.6 % for V1, 27.9 % for V2, 62.2 % for V3, and 78 % for V4-V5.

Conclusion

Critically ill patients with COVID-19 requiring vasopressors were associated with significantly higher 60-day mortality.

The Value of Right Heart Catheterization: Case Series Showing Benefits in a Variety of Diagnoses

Although the right heart catheterization (RHC) was first introduced in 1945, its use in the quantitative hemodynamic assessment of patients has remained of questionable benefit. With recent advances in pharmacotherapies and mechanical support devices, RHC has been increasingly used to assess and help tailor the management of more complex patient scenarios. We present a case series in which the use of the RHC was helpful in making complex medical decisions. (Level of Difficulty: Intermediate.).

Transcatheter Aortic Valve Implantation in Cardiac Amyloidosis and Aortic Stenosis

Aortic stenosis (AS) and cardiac amyloidosis (CA) occur concomitantly in a significant number of patients and portend a higher risk of all-cause mortality. Previous studies have investigated outcomes in patients with concomitant CA/AS who underwent transcatheter aortic valve implantation (TAVI) versus medical therapy alone, but no evidence-based consensus regarding the ideal management of these patients has been established. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Methodologic bias was assessed using the modified Newcastle-Ottawa scale for observational studies. A total of 4 observational studies comprising 83 patients were included. Of these, 45 patients (54%) underwent TAVI, whereas 38 (46%) were managed conservatively. Of the 3 studies that included baseline characteristics by treatment group, 30% were women. The risk of all-cause mortality was found to be significantly lower in patients who underwent TAVI than those treated with conservative medical therapy alone (odds ratio 0.24, 95% confidence interval 0.08 to 0.73). In conclusion, this meta-analysis suggests a lower risk of all-cause mortality in patients with CA with AS who underwent TAVI than those managed with medical therapy alone.

Adverse Outcomes of Atrial Fibrillation Ablation in Heart Failure Patients with and without Cardiac Amyloidosis: A Nationwide Readmissions Database Analysis (2015-2019)

Atrial fibrillation (AF) in patients with cardiac amyloidosis (CA) has been linked with a worse prognosis. The current study aimed to determine the outcomes of AF catheter ablation in patients with CA. The National Readmission Database (NRD) 2015-2019 was used to identify patients with AF and concomitant heart failure (HF). Among these, patients who underwent catheter ablation were classified into two groups, patients with and without CA. The adjusted odds ratio (aOR) of index-admission and 30-day readmission outcomes were calculated using a propensity score matched (PSM) analysis. A total of 148,134 patients with AF undergoing catheter ablation were identified on crude analysis. Using PSM analysis, 616 patients (293 CA-AF, 323 no-CA-AF) were selected based on a balanced distribution of baseline comorbidities. At index admission, AF ablation in patients with CA was associated with significantly higher adjusted odds of net adverse clinical events (NACE) (aOR 4.21, 95% CI 1.7-5.20), in-hospital mortality (aOR 9.03, 95% CI 1.12-72.70), and pericardial effusion (aOR 3.30, 95% CI 1.57-6.93) compared with non-CA AF. There was no significant difference in the odds of stroke, cardiac tamponade, and major bleeding between the two groups. At 30-day readmission, the incidence of NACE, and mortality remained high in patients undergoing AF ablation in CA. Compared with non-CA, AF ablation in CA patients is associated with relatively higher in-hospital all-cause mortality and net adverse events both at index admission and up to 30-day follow-up.

Percutaneous Decommissioning 11 Years After Initial CF-LVAD Placement

An 80-year-old man with severe nonischemic cardiomyopathy status post left ventricular assist device (LVAD) placement 11 years prior presented for recurrent LVAD alarms from internal driveline fracture. Given his partial myocardial recovery and his preference to avoid surgical procedures, percutaneous LVAD decommissioning was performed by occlusion of the outflow graft and subsequently driveline removal. (Level of Difficulty: Advanced.)

Cardiogenic Shock Due to Atrial Arrhythmia as the Initial Presentation of Transthyretin Cardiac Amyloidosis

Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.).

P03.02.B Vestibular side effects following robotic guided stereotactic radiosurgery of vestibular schwannoma

Background

New-onset vestibular disorders (VD), such as dizziness and imbalance, are common side effects after stereotactic radiosurgery (SRS) for vestibular schwannomas (VS). Although these symptoms can severely affect the daily life of VS patients, there are limited data available providing prognostic information on the risk of developing VD after SRS.

Material and Methods

We included patients who received Cyberknife® SRS for newly diagnosed unilateral VS between 2012 and 2015. The incidence of vestibular disorders before and after treatment was recorded and correlated with tumor, patient, and treatment characteristics.

Results

We identified 71 patients with a median age of 58 years (range: 21-82) and a median follow-up of 66 months (range: 3-105). Tumor volume before treatment was 1.5 cm3 ± 1.4 (range: 0.1-8.6). A mean marginal dose of 12.9 Gy ± 0.3 (range: 12-14) was administered, and all studied patients remained free of tumor recurrence. Forty-one (58%) of the patients had VD prior to SRS. Of the remaining 30 patients who did not have VD before treatment, 16 (53%) developed new VD (vertigo, n=4; balance disorders, n=8; mixture of VD, n=4). The median time to onset of symptoms was 6 months (range: 2-36). In most patients (n=11, 69%), the new symptoms completely resolved within a median time of 21 months (range: 1-63). In multivariate analysis, neither tumor volume (p=0.7), age (p=0.06), nor radiation dose (p=0.16) were significantly associated with the occurrence of VD.

Conclusion

In this cohort, about half of the patients develop new onset of transient VD after SRS. The incidence of VD after SRS was found to be independent from usual tumor-, patient- and treatment-related factors. Therefore, a detailed analysis of the dose exposure to the structures of the vestibular apparatus is recommended.

P13.03.A Radiomics for the non-invasive assessment of the PDL-1 expression in patients with non-small cell lung cancer brain metastases

BACKGROUND

The expression level of programmed cell death ligand 1 (PDL-1) might be an indicator for response to immunotherapy using checkpoint inhibitors in patients with non-small cell lung cancer (NSCLC). As intra-tumoral differences and discrepancies between the PDL-1 expression in the primary tumor and the brain metastases may occur, a method for a reliable non-invasive assessment of the intracranial PDL-1 expression would be of clinical value. We evaluated the potential of MRI radiomics for a non-invasive assessment of the PDL-1 expression in patients with NSCLC brain metastases.

PATIENTS AND METHODS

Fifty-three patients with brain metastases from NSCLC from two university brain tumor centers (group 1, 36 patients; group 2, 17 patients) underwent tumor resection with subsequent immunohistochemical assessment of the PDL-1 expression. Brain metastases were manually segmented on preoperative T1-weighted contrast-enhanced MRI. Group 1 was used for model training and validation, group 2 for model testing. After image pre-processing and radiomics feature extraction from T1-weighted contrast-enhanced MRI, a test-retest analysis was performed to identify robust features prior to feature selection. The radiomics model was trained and validated using five-fold cross validation. Finally, the best performing radiomics model was applied to the test data. Diagnostic performance was evaluated using receiver operating characteristic (ROC) analyses.

RESULTS

An intracranial PDL-1 expression was found by immunohistochemistry in 18 of 36 patients (50%) in group 1, and 7 of 17 patients (41%) in group 2. Univariate analysis identified tumor volume as a significant clinical feature for PDL-1 expression (area under the ROC curve (AUC), 0.77). A random forest classifier using a four-parameter radiomics signature including tumor volume yielded an AUC of 0.83 ± 0.18 in the training data (group 1). Finally, the classifier achieved an AUC of 0.84 in the external test data (group 2).

CONCLUSION

The developed radiomics classifiers allows a non-invasive assessment of the intracranial PD-L1 expression in patients with NSCLC brain metastases with a high diagnostic performance.

P03.01.A Late pseudoprogression of vestibular schwannoma after robotic guided stereotactic radiosurgery - Implications for follow-up

Background

Stereotactic radiosurgery (SRS) may cause transient changes of morphology and volume in vestibular schwannomas (VS). This may lead to difficulties in distinguishing treatment-related changes (pseudoprogression) from tumor recurrence (true progression), especially at 12-24 months after treatment. Therefore, we investigated the time course of volume changes of VS after robot-guided SRS.

Material and Methods

We included all patients with unilateral VS who underwent single fraction robotic guided SRS using the Cyberknife® with a minimum follow-up (FU) of 24 months and MR images ≤3 mm slice thickness. Tumor volumes were measured on T1-weighted contrast enhanced images. Volume changes (percentage of tumor volume change compared to baseline) during FU were classified according to RANO criteria (“partial response” (PR) (≥65% decrease), “stable disease” (SD) (&lt;65% decrease; &lt;20% increase), or “progressive disease” (PD) (≥40% increase)). A new status “pseudoprogression” (PP) (&gt;20% transient increase) was defined and divided into early (ePP, occurrence within first &lt;12 months) and late (lPP, &gt;12 months) PP.

Results

Overall 63 patients fulfilled the inclusion criteria. The median age was 56 years (range: 20-82) and the median initial tumor volume was 1.5 cm3 (range: 0.1 - 8.6). All patients received 13 Gy with an isodose level of 80%. The median radiological and clinical FU was 66 months (range: 24-103).

We found PR in 36% (n=23), SD in 35% (n=22) and PP in 29% (n=18). The latter was separated in ePP in 16% (n=10) and lPP in 13% (n=8). The median time to peak in the ePP was six months (range: 4 - 10) and in the lPP 35 months (range: 14 - 61). The median time to return from peak to baseline was seven months in the ePP (range: 5 - 20) and 18 months (range: 6 - 33) in the lPP group. Using these criteria no PD was observed. Additionally, we did not find any significant impact of radiation parameters (coverage, nCi, prescription dose, maximal dose) or patient related parameters (tumor volume, age) on the onset of early and/or late PP.

Conclusion

In our study, we demonstrated that any volume increase assumed to be PD turned out to be ePP or lPP. This might impact the management of VS treated with robotic SRS during FU in favour of further observation.

Impact of Ventricular Arrhythmia on LVAD Implantation Admission Outcomes

INTRODUCTION

Ventricular arrhythmias (VAs) are common after left ventricular assist device (LVAD) implantation though data are mixed on whether these events have an impact on mortality.

METHODS

The National Inpatient Sample (NIS) database from 2002 - 2019 was queried for LVAD implantation admissions. Secondary ICD codes were analyzed to assess for the occurrence of VAs during this admission. Propensity score matching (PSM) was used to control for confounding variables between those with versus without VAs.

RESULTS

The NIS database from 2002 - 2019 contained 43,936 admissions with LVAD implantation. VAs occurred in 19,985 (45.4%) patients. After PSM, the study cohort consisted of 39,989 patients, 19,985 (50.0%) of which had a secondary diagnosis of VA during the admission. When compared to those without VA, those with VA were at no higher risk for in-hospital mortality (adjusted odds ratio 1.011, 99.9% CI 0.956 - 1.069, p = 0.699). Those with a VA were at higher risk for cardiogenic shock and requiring mechanical ventilation, tracheostomy, and percutaneous endoscopic gastrostomy placement. Patients with a VA were also at lower risk for device thrombosis. Conversely, the VA group was at no higher risk for stroke. In comparing trends from 2002 to 2019, the incidence of VAs has increased, while the mortality rate of those with and without VAs has decreased during this same period.

CONCLUSION

In this retrospective study of the NIS database, VAs were common (45.4%) during the LVAD implantation admission. However, the occurrence of VAs during the implantation admission did not alter in-hospital mortality. More longitudinal studies are required to assess the long-term impact of VAs on mortality. In comparing trends from 2002 - 2019, the incidence of VAs has increased, while the mortality rate of those with and without VAs has decreased.

Clinical outcomes of COVID-19 infection in patients with pre-existing cardiovascular disease

Introduction

Patients with pre-existing cardiovascular disease may carry a higher risk for mortality from COVID-19. This study examined the association between individuals with pre-existing cardiovascular disease admitted for COVID-19 and their clinical outcomes.

Methods

A retrospective cohort study was conducted on patients admitted with COVID-19 to Rush University System for Health (RUSH) to identify cardiovascular risk factors associated with increased mortality and major adverse cardiovascular events (MACE; a composite of cardiovascular death, stroke, myocardial injury, and heart failure exacerbation). Multivariable logistic regression was used to adjust for demographic data and comorbid conditions.

Results

Of the 1682 patients who met inclusion criteria, the median age was 59. Patients were predominantly African American (34.4 %) and male (54.5 %). Overall, 202 (12 %) patients suffered 60-day mortality. In the multivariable model that assessed risk factors for 60-day mortality, age 60–74 (adjusted odds ratio [aOR] 3.30 [CI: 1.23–10.62]; p < 0.05) and age 75–100 (aOR 4.52 [CI: 1.46–16.15]; p < 0.05) were significant predictors when compared to those aged 19 to 39. This model also showed that those with past medical histories of atrial fibrillation (aOR 2.47 [CI: 1.38–4.38]; p < 0.01) and venous thromboembolism (aOR 2.00 [CI: 1.12–3.50]; p < 0.05) were at higher risk of 60-day mortality.

Conclusion

In this cohort, patients over 60 years old with a pre-existing history of atrial fibrillation and venous thromboembolism were at increased risk of mortality from COVID-19.

IVC measurement for the noninvasive evaluation of central venous pressure

Central venous pressure (CVP) is one of only a handful of variables that can be used to assess a patient's volume status to attempt to optimize stroke volume. The gold standard method for assessing CVP is though pulmonary artery catheterization, which is invasive and risks severe complications such as pneumothorax and cardiac conduction abnormalities. Current noninvasive methods for estimating CVP such as jugular venous pressure assessment are imperfect with wide inter-examiner variability. The inferior vena cava (IVC) is a highly compliant vessel that uniquely does not constrict in response to hypovolemia, making it an ideal, noninvasive surrogate for the estimation of CVP. A range of IVC indices including minimum and maximum IVC diameter and fraction of IVC collapse with inspiration (known as collapsibility index) have been studied with highly variable results that range from excellent to poor correlation between these values and CVP. Despite this inconsistency in findings, multiple schemes have been proposed to attempt to estimate CVP from IVC measurements, but when prospectively tested, none has been shown to be accurate. Since the most recent 2015 American Society of Echocardiography guidelines, multiple studies have identified unique ways of improving the accuracy of IVC measurement, which could translate into better CVP estimation. The goal of this review is to summarize the many, often conflicting studies that exist in this area, and provide recommendations for future studies based on our findings.

Hyperdynamic left ventricular ejection fraction is associated with higher mortality in COVID-19 patients

Study objective

To compare the characteristics and outcomes of COVID-19 patients with a hyperdynamic LVEF (HDLVEF) to those with a normal or reduced LVEF.

Design

Retrospective study.

Setting

Rush University Medical Center.

Participants

Of the 1682 adult patients hospitalized with COVID-19, 419 had a transthoracic echocardiogram (TTE) during admission and met study inclusion criteria.

Interventions

Participants were divided into reduced (LVEF < 50%), normal (≥50% and <70%), and hyperdynamic (≥70%) LVEF groups.

Main outcome measures

LVEF was assessed as a predictor of 60-day mortality. Logistic regression was used to adjust for age and BMI.

Results

There was no difference in 60-day mortality between patients in the reduced LVEF and normal LVEF groups (adjusted odds ratio [aOR] 0.87, p = 0.68). However, patients with an HDLVEF were more likely to die by 60 days compared to patients in the normal LVEF group (aOR 2.63 [CI: 1.36–5.05]; p < 0.01). The HDLVEF group was also at higher risk for 60-day mortality than the reduced LVEF group (aOR 3.34 [CI: 1.39–8.42]; p < 0.01).

Conclusion

The presence of hyperdynamic LVEF during a COVID-19 hospitalization was associated with an increased risk of 60-day mortality, the requirement for mechanical ventilation, vasopressors, and intensive care unit.

Prognostic value of H2FPEF score in COVID-19

Study objective

This study sought to assess the predictive value of H₂FPEF score in patients with COVID-19.

Design

Retrospective study.

Setting

Rush University Medical Center.

Participants

A total of 1682 patients had an echocardiogram in the year preceding their COVID-19 admission with a preserved ejection fraction (≥50%). A total of 156 patients met inclusion criteria.

Interventions

Patients were divided into H₂FPEF into low (0–2), intermediate (3–5), and high (6–9) score H₂FPEF groups and outcomes were compared.

Main outcome measures

Adjusted multivariable logistic regression models evaluated the association between H₂FPEF score group and a composite outcome for severe COVID-19 infection consisting of (1) 60-day mortality or illness requiring (2) intensive care unit, (3) intubation, or (4) non-invasive positive pressure ventilation.

Results

High H₂FPEF scores were at increased risk for severe COVID-19 infection when compared intermediate to H₂FPEF score groups (OR 2.18 [CI: 1.01–4.80]; p = 0.049) and low H₂FPEF score groups (OR 2.99 [CI: 1.22–7.61]; p < 0.05). There was no difference in outcome between intermediate H₂FPEF scores (OR 1.34 [CI: 0.59–3.16]; p = 0.489) and low H₂FPEF score.

Conclusions

Patients with a high H₂FPEF score were at increased risk for severe COVID-19 infection when compared to patients with an intermediate or low H₂FPEF score regardless of regardless of coronary artery disease and chronic kidney disease.

Cardiovascular findings on chest computed tomography associated with COVID-19 adverse clinical outcomes

STUDY OBJECTIVE

Chest computed tomography (chest CT) is routinely obtained to assess disease severity in COVID-19. While pulmonary findings are well-described in COVID-19, the implications of cardiovascular findings are less well understood. We evaluated the impact of cardiovascular findings on chest CT on the adverse composite outcome (ACO) of hospitalized COVID-19 patients.

SETTING/PARTICIPANTS

245 COVID-19 patients who underwent chest CT at Rush University Health System were included.

DESIGN

Cardiovascular findings, including coronary artery calcification (CAC), aortic calcification, signs of right ventricular strain [right ventricular to left ventricular diameter ratio, pulmonary artery to aorta diameter ratio, interventricular septal position, and inferior vena cava (IVC) reflux], were measured by trained physicians.

INTERVENTIONS/MAIN OUTCOME MEASURES

These findings, along with pulmonary findings, were analyzed using univariable logistic analysis to determine the risk of ACO defined as intensive care admission, need for non-invasive positive pressure ventilation, intubation, in-hospital and 60-day mortality. Secondary endpoints included individual components of the ACO.

RESULTS

Aortic calcification was independently associated with an increased risk of the ACO (odds ratio 1.86, 95% confidence interval (1.11-3.17) p < 0.05). Aortic calcification, CAC, abnormal septal position, or IVC reflux of contrast were all significantly associated with 60-day mortality and major adverse cardiovascular events. IVC reflux was associated with in-hospital mortality (p = 0.005).

CONCLUSION

Incidental cardiovascular findings on chest CT are clinically important imaging markers in COVID-19. It is important to ascertain and routinely report cardiovascular findings on CT imaging of COVID-19 patients as they have potential to identify high risk patients.

In-hospital predictors of 60-day readmission in COVID-19 patients

Introduction

Preventing hospital readmissions can improve a patient's quality of life and decrease healthcare costs. While prior work has focused on pre-existing comorbidities to predict COVID-19 readmissions, the prognostic role of in-hospital data and complications has been less studied.

Methods

Data was collected on adult patients diagnosed with COVID-19 and admitted to a multicenter hospital system in Illinois between March and November 2020. Our cohort consisted of COVID-19 hospitalization survivors excluding those discharged to hospice care. Major adverse events (MAEs) were defined as venous thromboembolism (VTE), myocardial injury (troponin greater than upper limit of normal), stroke, new requirement for renal replacement therapy (RRT), life-threatening arrhythmia, or acute heart failure exacerbation. The primary outcome was readmission within 60 days of initial hospitalization.

Results

From the 1406 survivors of the index hospitalization, 223 (15.9%) patients were readmitted within 60 days. Those readmitted were older and more likely to have underlying comorbidities including atrial fibrillation, coronary artery disease, and hypertension (Table 1). Length of stay between the readmission and non-readmission groups was trending towards statistical significance (10.52 days vs 8.95 days, p=0.053).

Those with one or more MAE during their index hospitalization, when adjusted for age and body mass index, were at an increased risk of readmission (adjusted odds ratio [aOR] 1.90, p&lt;0.01). Readmitted patients were more likely to have VTE during their index hospitalization than those not readmitted (7.2% vs 3.7%, p&lt;0.05). The incidence of new RRT (4.9% vs 2.5%, p=0.083) and myocardial injury (3.6% vs 1.5%, p=0.067) between the groups was also trending towards statistical significance (Table 1). No statistical difference was present between the other individual MAEs; however, this is limited by small sample sizes of certain MAEs. Of the 322 patients with echocardiography during the index admission, 82 (25.5%) were readmitted. In this cohort, left ventricular ejection fraction (LVEF) that was reduced (LVEF &lt;50%) or hyperdynamic (LVEF &gt;65%) was not a statistically significant predictor of readmission (Figure 1).

Lastly, discharge disposition was predictive of readmission as those being sent to acute rehab (OR 2.04, p&lt;0.01), long-term acute care (OR 2.58, p&lt;0.01), or skilled nursing facility (OR 2.67, p&lt;0.001) were at higher risk compared to those who were discharged to home (Figure 1).

Conclusion

In this cohort, the occurrence of any MAE during index COVID-19 hospitalization, particularly VTE, RRT, and myocardial injury, can be used to predict 60-day readmission. Furthermore, discharge disposition, but not LVEF, demonstrated prognostic value in our cohort. Identifying high risk patients prior to discharge helps health care providers focus resources on patients most likely to be readmitted.

Funding Acknowledgement

Type of funding sources: None.

P14.79 Differentiation of treatment-related changes from tumor progression following brachytherapy in patients with WHO II and III gliomas using FET PET

BACKGROUND

Following brachytherapy, the differentiation of radiation-induced changes (e.g., radiation necrosis) from actual tumor progression using MRI is challenging. To overcome this diagnostic uncertainty, we evaluated the diagnostic value of O-(2-[18F]-fluoroethyl)-L-tyrosine (FET) PET in glioma patients treated with brachytherapy.

MATERIAL AND METHODS

From 2006–2019, we retrospectively identified WHO grade II or III glioma patients (i) treated with brachytherapy using Iodine-125 seeds, (ii) equivocal or progressive MRI findings inside the radiation field, and (iii) additional FET PET imaging for diagnostic evaluation. Static FET PET parameters such as maximum and mean tumor-to-brain ratios (TBR) and dynamic FET PET parameters (i.e., time-to-peak, slope) were obtained. Diagnostic performances were calculated using receiver operating characteristic curve analyses and Fisher’s exact test. Diagnoses were confirmed histologically or clinicoradiologically.

RESULTS

Following brachytherapy, suspect MRI findings occurred after a median time of 33 months (range, 5–111 months). In 10 of 21 patients (WHO grade II, n=5; WHO grade III, n=16), treatment-related changes were diagnosed. The best diagnostic performance for identification of treatment-related changes was obtained using maximum TBRs (threshold &lt;3.20; accuracy, 86%; sensitivity, 100%; specificity, 73%; P=0.007). Mean TBRs reached an accuracy of 76% (threshold &lt;2.05; sensitivity, 89%; specificity, 64%; P=0.010). Dynamic PET parameters did not reach statistically significant results.

CONCLUSION

Our data suggest that static FET PET parameters add valuable diagnostic information to diagnose radiation-induced changes in glioma patients treated with brachytherapy.

The prognostic value of cardiac troponin for 60 day mortality and major adverse events in COVID-19 patients

BACKGROUND

The variability of coronavirus disease 2019 (COVID-19) illness severity has puzzled clinicians and has sparked efforts to better predict who would benefit from rapid intervention. One promising biomarker for in-hospital morbidity and mortality is cardiac troponin (cTn).

METHODS

A retrospective study of 1331 adult patients with COVID-19 admitted to the Rush University System in Illinois, USA was performed. Patients without cTn measurement during their admission or a history of end stage renal disease or stage 5 chronic kidney disease were excluded. Using logistic regression adjusted for baseline characteristics, pre-existing comorbidities, and other laboratory markers of inflammation, cTn was assessed as a predictor of 60-day mortality and severe COVID-19 infection, consisting of a composite of 60-day mortality, need for intensive care unit, or requiring non-invasive positive pressure ventilation or intubation.

RESULTS

A total of 772 patients met inclusion criteria. Of these, 69 (8.9%) had mild cTn elevation (> 1 to < 2x upper limit of normal (ULN)) and 46 (6.0%) had severe cTn elevation (≥ 2x ULN). Regardless of baseline characteristics, comorbidities, and initial c-reactive protein, lactate dehydrogenase, and ferritin, when compared to the normal cTn group, mild cTn elevation and severe cTn elevation were predictors of severe COVID-19 infection (adjusted OR [aOR] aOR 3.00 [CI: 1.51 - 6.29], P < 0.01; aOR 9.96 [CI: 2.75 - 64.23], P < 0.01, respectively); severe cTn elevation was a predictor of in-hospital mortality (aOR 2.42 [CI: 1.10 - 5.21], P < 0.05) and 60-day mortality (aOR 2.45 [CI: 1.13 - 5.25], P < 0.05).

CONCLUSION

In our cohort, both mild and severe initial cTn elevation were predictors of severe COVID-19 infection, while only severe cTn elevation was predictive of 60-day mortality. First cTn value on hospitalization is a valuable longitudinal prognosticator for COVID-19 disease severity and mortality.

Impact of pre-existing heart failure on 60-day outcomes in patients hospitalized with COVID-19

Background

In the coronavirus disease 2019 (COVID-19) global pandemic, patients with cardiovascular disease represent a vulnerable population with higher risk for contracting COVID-19 and worse prognosis with higher case fatality rates. However, the relationship between COVID-19 and heart failure (HF) is unclear, specifically whether HF is an independent risk factor for severe infection or if other accompanying comorbidities are responsible for the increased risk.

Methods

This is a retrospective analysis of 1331 adult patients diagnosed with COVID-19 infection between March and June 2020 admitted at Rush University System for Health (RUSH) in metropolitan Chicago, Illinois, USA. Patients with history of HF were identified by International Classification of Disease, Tenth Revision (ICD-10) code assignments extracted from the electronic medical record. Propensity score matching was utilized to control for the numerous confounders, and univariable logistic regression was performed to assess the relationship between HF and 60-day morbidity and mortality outcomes.

Results

The propensity score matched cohort consisted of 188 patients in both the HF and no HF groups. HF patients did not have lower 60-day mortality (OR 0.81; p = 0.43) compared to patients without HF. However, those with HF were more likely to require readmission within 60 days (OR 2.88; p < 0.001) and sustain myocardial injury defined as troponin elevation within 60 days (OR 3.14; p < 0.05).

Conclusions

This study highlights the complex network of confounders present between HF and COVID-19. When balanced for these numerous factors, those with HF appear to be at no higher risk of 60-day mortality from COVID-19 but are at increased risk for morbidity.

[Brain metastases-Interdisciplinary approach towards a personalized treatment]

The incidence, treatment and prognosis of patients with brain metastases have substantially changed during the last decades. While the survival time after diagnosis of cerebral metastases was on average a maximum of 3-6 months only 10 years ago, the survival time could be significantly improved due to novel surgical, radiotherapeutic and systemic treatment modalities. Only a few years ago, the occurrence of brain metastases led to a withdrawal from systemic oncological treatment and the exclusion of drug therapy studies and to a purely palliatively oriented treatment in the sense of whole brain radiation therapy (WBRT) with or without surgery. The increasing availability of targeted and immunomodulatory drugs as well as adapted radio-oncological procedures enable increasingly more personalized treatment approaches. The aim of this review article is to demonstrate the progress and complexity of the treatment of brain metastases in the context of modern comprehensive interdisciplinary concepts.

Surgical resection plus stereotactic 125I brachytherapy in adult patients with eloquently located supratentorial WHO grade II glioma - feasibility and outcome of a combined local treatment concept

OBJECTIVE

The current pilot study analyzed feasibility, risk and effectiveness of 1) microsurgery plus stereotactic iodine-125 ((125)I) brachytherapy (SBT) for large (diameter > 4 cm), circumscribed, and complex located WHO grade II glioma and 2) SBT alone for small (diameter < 4 cm), and complex located recurrences.

METHODS

Lowactivity temporary (125)I seeds were used. The applied reference dose was 54 Gy and the dose rate was low (median, 10 cGy/h). Time to progression and time to additional external beam radiation (EBR) and/or chemotherapy were estimated with the Kaplan-Meier method. Any adverse sequel potentially attributable to treatment was classified as morbidity. Treatment effects of SBT were estimated according to the modified MacDonald criteria.

RESULTS

Thirtyone patients (de novo group: n = 18, recurrence group: n = 13) were included. The median tumor volume before surgery was 66 ml. A planned partial tumor resection achieved eligibility for SBT in all patients. Transient morbidity of microsurgery and SBT was 27.8 % and 6.4 %, respectively. There was no permanent morbidity. Radiogenic complications did not occur. Complete response, partial response, and stable disease were seen in 8, 9, and 14 patients, respectively. Ten patients exhibited tumor progression (overall 5-year progression- free survival > 60 %). The 5-year probability to receive chemotherapy and/or EBR was 18 %.

CONCLUSION

A planned partial tumor resection of large and complex located WHO grade II glioma is safe. SBT of small and complex located residual of recurrent tumors is safe and minimally invasive. Combined treatment may provide the possibility to withhold EBR and/or chemotherapy for a considerable number of patients and deserves further prospective evaluation.

Impact of epidermal growth factor (EGF) radioreceptor analysis on long-term survival of gastric cancer patients

BACKGROUND

The EGF receptor/ligand system seems to be involved in the regulation of gastric mucosa proliferation and progression of gastric carcinomas.

PATIENTS AND METHODS

EGF receptor levels were quantitatively determined in 47 gastric carcinomas by 125J [EGF] radioreceptor assays in membrane preparations of tumor samples or corresponding adjacent mucosa. Specific receptor binding was determined by the analysis of displacement curves by non-linear least-square regression analysis using an estimated model of 'goodness of fit'.

RESULTS

Increased EGF receptor binding was observed in gastric carcinomas (mean +/- SEM: 11.87 +/- 1.9 fmol/mg protein) in comparison to adjacent normal gastric mucosa ( 5.28 +/- 1.0 fmol/mg protein, p = 0.003). Elevated EGF receptor levels were especially found in more invasive T3/4 carcinomas, tumors with positive lymph nodes, advanced UICC III carcinomas, undifferentiated tumors, carcinomas of the diffuse-type according to Lauren's classification and gastric carcinomas localized distal from the cardia. In histopathologically normal appearing gastric mucosa, EGF-receptor levels were significantly decreased relative to corresponding tumor samples from advanced UICC stages (UICC I vs UICC I/II: p = 0.008) or tumors with low levels of differentiation (G2 vs G3: p = 0.028). Overall survival was significantly reduced in patients with advanced gastric carcinomas according to UICC classification (UICC III vs UICC I/II: 18.8 vs 45.5 months, p = 0.016). A subgroup analysis of gastric carcinomas localized distal from the cardia indicated, that increased EGF-receptor levels were an independent indicator of poor prognosis as determined by univariate (p = 0.020) and multivariate analysis (p = 0.042).

CONCLUSION

Gastric carcinomas with increased EGF receptors might be a possible target for anticancer strategies blocking the EGF receptor/ligand pathway.

Epidermal-growth-factor receptor correlates negatively with cell density in cervical squamous epithelium and is down-regulated in cancers of the human uterus

The role of the epidermal-growth-factor receptor (EGFR) in cervical cancer is controversial, due to technical difficulties in localizing or in quantifying EGFR by homogenate assays or immunohistochemistry. Our autoradiographic approach, in combination with morphometry, allowed cell-type-specific quantification of EGFR, leading to the following observations: (i) In normal cervical epithelium, EGFR levels per cell were high in non-dividing squamous cells of the upper layers of normal epithelium, where a mitogenic function of these EGFRs can be excluded. (ii) In contrast to earlier findings in tissue homogenates, but consistent with our observation in normal cervical epithelium that cells of the proliferating strata (basal and parabasal cells) express intermediate and comparatively reduced levels of EGFR per cell, cervical cancers displayed a significant reduction both of specific EGF binding and of EGFR levels per cell as compared with normal epithelium. (iii) A significant negative correlation of cell density and EGFR number per cell was obtained. In normal cervical epithelium, cervical intra-epithelial neoplasia and invasive cervical cancer (p = 0.002). This negative correlation was most evident in normal epithelium, where large changes of cell density occur within one slide (p < 0.001). (iv) Specific EGF-binding was also significantly reduced in endometrial cancers when compared with normal endometrium. It is proposed that in uterine tissues low or intermediate levels of EGFR do not exclude their function as mediators of cell proliferation.

Blood-brain barrier breakdown occurs early after traumatic brain injury and is not related to white blood cell adherence

The time course of blood-brain barrier (BBB) breakdown after traumatic brain injury (TBI) has important implications for therapy. This study was conducted in order to test post-traumatic BBB dysfunction in a model of fluid-percussion induced TBI in rabbits at 1 and 6 hours after TBI and relate it to white blood cell (WBC) activation. Ten anesthetized rabbits had chronic cranial windows implanted three weeks prior to experimentation. Fluid-percussion injury (3.5 atm.) was induced and animals were followed for 1 or 6 h. Intravital fluorescence videomicroscopy was used to assess BBB permeability and WBC adhesion to pial venules. Na(+)-fluorescein was infused continuously over 30 min at either 30 min (Group I, n = 5) or 5.5 h (Group II, n = 5) after TBI. Microvascular permeability in individual postcapillary venules was assessed qualitatively at 1 and 30 min after start of infusion. TBI led to a transient mean arterial blood pressure (MAP) surge after trauma and a progressive increase in the number of sticking WBCs per mm2 vessel wall. Na(+)-fluorescein extravasation was observed in 4 out of 5 Group I animals and in none of Group II. BBB breakdown was not associated with WBC sticking. We conclude that after fluid-percussion injury the BBB is damaged at 1 h post-trauma and that its function is restored 6 h later. Increased WBC sticking at 6 h is not associated with BBB breakdown. Whether WBCs may cause vascular permeability changes at a later point needs further investigation.

Early white blood cell dynamics after traumatic brain injury: effects on the cerebral microcirculation

Increasing clinical and experimental evidence suggests that traumatic brain injury (TBI) elicits an acute inflammatory response. In the present study we investigated whether white blood cells (WBC) are activated in the cerebral microcirculation early after TBI and whether WBC accumulation affects the posttraumatic cerebrovascular response. Twenty-four anesthetized rabbits had chronic cranial windows implanted 3 weeks before experimentation. Animals were divided into four experimental groups and were studied for 7 hours (groups I, IIa, and III) or 2 hours (group IIb). Intravital fluorescence videomicroscopy was used to visualize WBC (rhodamine 6G, intravenously), pial vessel diameters, and blood-brain barrier (BBB) integrity (Na+-fluorescein) at 6 hours (groups I, IIa, and III) or 1 hour (group IIb) after TBI. Group I (n = 5) consisted of sham-operated animals. Groups IIa (n = 7) and IIb (n = 5) received fluid-percussion injury at 1 hour. Group III (n = 7) received fluid-percussion injury and 1 mg/kg anti-adhesion monoclonal antibody (MoAb) "IB4" 5 minutes before injury. Venular WBC sticking, intracranial pressure (ICP), and arterial vessel diameters increased significantly for 6 hours after trauma. IB4 reduced WBC margination and prevented vasodilation. Intracranial pressure was not reduced by treatment with IB4. Blood-brain barrier damage occurred at 1 hour but not at 6 hours after TBI and was independent of WBC activation. This first report using intravital videomicroscopy to study the inflammatory response after TBI reveals upregulated interaction between WBC and cerebral endothelium that can be manipulated pharmacologically. White blood cell activation is associated with pial arteriolar vasodilation. White blood cells do not induce BBB breakdown less than 6 hours after TBI and do not contribute to posttraumatic ICP elevation. The role of WBC more than 6 hours after TBI should be investigated further.

Hypertonic/hyperoncotic saline attenuates microcirculatory disturbances after traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) induces an acute inflammatory response characterized by early recruitment of inflammatory cells (white blood cells). Rapid resuscitation of TBI with hypertonic saline/dextran (HS/DEX) yields promising results in clinical and experimental studies. The purpose of this paper was to test the hypothesis that HS/DEX exerts its effects in part through a modulation of the acute inflammatory response to TBI.

METHODS

Rabbits equipped with chronic cranial windows underwent fluid-percussion injury and were followed up for 6 hours. Intravital fluorescence videomicroscopy technique was used to visualize white blood cell trafficking and to measure pia vessel diameters and venular shear rates. Three groups were studied: sham (group I, n = 5), trauma (group II, n = 7), and trauma and 4 mL/kg 7.2% NaCl/10% dextran 60 IV over 5 minutes at 10 minutes after TBI (group III, n = 7).

RESULTS

TBI in groups II and III led to significant increases of intracranial pressure. Arteriolar diameters after trauma increased by 17 +/- 8% at 6 hours in group II. Infusion of HS/DEX completely prevented this secondary diameters increase. At 6 hours, the increase of "sticking" white blood cells in group III was reduced by approximately 90% compared with group II.

CONCLUSIONS

Whether the anti-inflammatory effect of HS/DEX plays a role in reducing delayed brain damage (> 6 hours after TBI) or other systemic complications of TBI arises as an important question and should be investigated further.

The superinfection exclusion gene (sieA) of bacteriophage P22: identification and overexpression of the gene and localization of the gene product

Previous work has shown that the sieA gene of Salmonella bacteriophage P22 is located between the genes mnt and 16. We cloned DNA fragments of the region into multicopy vectors and tested the transformants for mediating superinfection exclusion. Subcloning, phenotypical tests, and DNA sequencing resulted in the identification of the sieA gene. There are two possible initiation codons within one open reading frame of 492 or 480 bp. The deduced amino acid sequence leads to a hypothetical polypeptide with a calculated molecular mass of 18.8 or 18.3 kDa, respectively. According to three hydrophobic regions, all of which are long enough to span the membrane, the product of sieA should be a protein of the inner membrane of a P22-lysogenic cell of Salmonella typhimurium. The SieA protein was moderately overproduced from an expression vector in cultures of Escherichia coli and could be recovered from the membrane fraction.

Muscarinic receptors in gastric mucosa are increased in peptic ulcer disease

Muscarinic receptors stimulate the secretion of acid pepsinogen and mucous in gastric mucosa. Whether muscarinic receptors are involved in the pathogenesis of benign gastric disease is unknown. Receptor changes in these conditions were therefore sought. An autoradiographic technique was developed to determine quantitatively muscarinic receptors in microtome sections of biopsy specimens obtained during gastroscopy. Muscarinic receptor density was mean (SEM) 18.4 (1.2) fmol/mg protein in the corpus and 8.9 (0.7) fmol/mg protein in the antrum (n = 53). Neither chronic nor active gastritis was associated with receptor changes in the antrum but chronic gastritis was associated with a receptor loss in the corpus. Patients with acute or recent duodenal or antral ulcers (n = 23) had significantly higher levels of muscarinic receptors in the corpus than controls (n = 25) (22.2 (1.5) v 16.9 (1.7) fmol/mg protein respectively (p < 0.025). These results suggest that muscarinic M3 receptor is overexpressed in duodenal ulcer disease and may play a part in its pathogenesis.