Three-dimensional radiographic assessment of the mandibular interforaminal donor site in different vertical facial growth types

PURPOSE

To assess volumetrically, the impact of vertical facial growth types (VFGT) on the mandibular interforaminal region as a potential bone donor site.

MATERIAL AND METHODS

60 cone beam computed tomography (CBCT) scans of adult individuals were classified in three groups according to their SN-GoGn angle: hypodivergent group (hG) (N=20), normodivergent group (NG) (N=19) and hyperdivergent group (HG) (N=21). Total harvestable bone volume (TBV), cortico-cancellous bone volume (CBV-cBV), and cortical bone surface (CBS) were evaluated. ANOVA test followed by Tukey post hoc tests were used to compare the mean continuous outcomes according to their VFGT.

RESULTS

The whole sample showed a mean TBV of 1376.32±541.01mm³, CBV of 468.52±121.54mm³ and cBV of 908.73±474.71mm³. The mean CBS amounted to 782.58±146.80mm². The comparison between the groups stated a significantly different mean TBV and cBV (-p-value<0.001). The mean CBS was significantly different (-p-value=0.015): the smallest for the NG, but not significantly different (-p-value<0.001): the highest for the HG, intermediate for the NG and the smallest for the hG.

CONCLUSION

Hypodivergent individuals have the thickest cancellous bone suitable for an onlay bone graft, while hyperdivergent individuals have the thinnest bone ideal for a 3D grafting approach.

Periodontal Inflammation Primes the Systemic Innate Immune Response

The presence of periodontal diseases (PDs) often strongly correlates with other severe chronic inflammatory conditions, including cardiovascular disease, diabetes, and arthritis. However, the mechanisms through which these diseases interact are unclear. In PD, tissue and bone destruction in the mouth is driven by elevated recruitment of polymorphonuclear neutrophils (PMNs), which are primed and recruited from the circulation to sites of inflammation. We predicted that systemic effects on PMN mobilization or priming could account for the interaction between PD and other inflammatory conditions. We tested this using a mouse model of ligature-induced PD and found elevated PMN counts specifically in bone marrow, supporting a systemic effect of periodontal tissue inflammation on PMN production. In contrast, mice with induced peritonitis had elevated PMN counts in the blood, peritoneum, and colon. These elevated counts were further significantly increased when acute peritonitis was induced after ligature-induced PD in mice, revealing a synergistic effect of multiple inflammatory events on PMN levels. Flow cytometric analysis of CD marker expression revealed enhanced priming of PMNs from mice with both PD and peritonitis compared to mice with peritonitis alone. Thus, systemic factors associated with PD produce hyperinflammatory PMN responses during a secondary infection. To analyze this systemic effect in humans, we induced gingival inflammation in volunteers and also found significantly increased activation of blood PMNs in response to ex vivo stimulation, which reverted to normal following resolution of gingivitis. Together, these results demonstrate that periodontal tissue inflammation has systemic effects that predispose toward an exacerbated innate immune response. This indicates that peripheral PMNs can respond synergistically to simultaneous and remote inflammatory triggers and therefore contribute to the interaction between PD and other inflammatory conditions. This suggests larger implications of PD beyond oral health and reveals potential new approaches for treating systemic inflammatory diseases that interact with PD.

Association of Blood Pressure During Thrombectomy for Acute Ischemic Stroke With Functional Outcome: A Systematic Review

Background and Purpose- Optimal blood pressure (BP) targets during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are unknown, and randomized controlled trials addressing this issue are lacking. We aimed to perform a systematic review of studies evaluating the influence of periprocedural BP on functional outcome after MT. Methods- Studies assessing periprocedural BP effect on functional outcome published after January 1st, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results- Nine studies were included, for a total of 1037 patients. The heterogeneity in findings with respect to BP monitoring and studied parameters precluded a meta-analysis. Mean arterial pressure was the most frequently reported parameter to describe BP variability during MT, and systolic BP was the main parameter used to define periprocedural BP targets. Five studies suggested an association between 3 types of BP drops as predictors of poor functional outcome at 3 months: >40% drop in mean arterial pressure compared with baseline (odds ratio=2.8; [1.09-7.19]; P=0.032), lowest mean arterial pressure before recanalization (odds ratio=1.28; [1.01-1.62] per 10 mm Hg drop below 100 mm Hg; P=0.04), and MAP drops (odds ratio=4.38; [1.53-12.6] for drops >10%). Four studies did not show an association between BP during MT and functional outcome, including 3 studies with strict periprocedural systolic BP targets (within a 140-180 mm Hg). Conclusions- BP drops during MT may be associated with a worse functional outcome. When strict systolic BP targets are achieved, no association between BP and functional outcome was also noted. Both conclusions require further evaluation in randomized studies.

Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study

Background and Purpose

Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy.

Methods

Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH.

Results

A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00–1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P<0.001) were identified as independent predictors of PH.

Conclusions

PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.

Visual assessment of diffusion weighted imaging infarct volume lacks accuracy and reliability

Purpose

The DAWN trial (Diffusion weighted imaging or CT perfusion Assessment with clinical mismatch in the triage of Wake-up and late presenting strokes undergoing Neurointervention with Trevo) has demonstrated the benefits of thrombectomy in patients with unknown or late onset strokes, using automated software (RAPID) for measurement of infarct volume. Because RAPID is not available in all centers, we aimed to assess the accuracy and repeatability of visual infarct volume estimation by clinicians and the consequences for thrombectomy decisions based on the DAWN criteria.

Materials and methods

18 physicians, who routinely depend on MRI for acute stroke imaging, assessed 32 MR scans selected from a prospective databaseover two independent sessions. Raters were asked to visually estimate the diffusion weighted imaging (DWI) infarct volume for each case. Sensitivity, specificity, and accuracy of the estimated volumes were compared with the available RAPID measurements for various volume cut-off points. Thrombectomy decisions based on DAWN criteria with RAPID measurements and raters’ visual estimates were compared. Inter-rater and intra-rater agreement was measured using kappa statistics.

Results

The mean accuracy of raters was <90% for all volume cut-points. Inter-rater agreement was below substantial for each DWI infarct volume cut-off points. Intra-rater agreement was substantial for 55–83% of raters, depending on the selected cut-off points. Applying DAWN criteria with visual estimates instead of RAPID measurements led to 19% erroneous thrombectomy decisions, and showed a lack of reproducibility.

Conclusion

The visual assessment of DWI infarct volume lacks accuracy and repeatability, and could lead to a significant number of erroneous decisions when applying the DAWN criteria.

Abstract TP68: Visual Assessment of Diffusion-Weighted-Imaging Infarct Volume Lacks Accuracy and Reliability

Introduction: Patients screened by MRI in the extended window (6-24hr) for mechanical thrombectomy (MT) might require the treating physician to visually estimate the DWI infarct volume at institutions where the RAPID software is not available. We aimed to assess the accuracy of DWI volume estimation compared with RAPID, as well as the interrater and intrarater agreement among physicians.

Methods: Eighteen raters (all physicians involved on daily stroke management) assessed over two independent sessions 32 MR scans from a prospective MT database. Raters generated a visual estimate of the DWI infarct volume and were asked whether they would recommend MT for the assessed patient or not. Sensitivity, specificity and accuracy of the estimated volumes were compared with the available RAPID measurements for various volume cut-points. Interrater and intrarater agreement was measured using Fleiss’ kappa statistics.

Results: Raters mean accuracy was <90% for all volume cut-points ( A ). Interrater agreement was below substantial for each DWI infarct volume cut-point ( B ). Intrarater agreement was substantial for 55-83% of raters, depending on the selected cut-point ( C ). Raters recommended MT for a mean of 77% of patients, including a mean of 56% of patients with an estimated infarct volume≥71ml.

Conclusion: The visual assessment of DWI infarct volume lacks accuracy when RAPID measurements are the reference values. Less-than-substantial reproducibility of the volume estimates was demonstrated among physician raters who recommended MT for large infarct volumes despite the absence of rigorous scientific evidence.

Gadolinium-Enhanced Extracranial MRA Prior to Mechanical Thrombectomy Is Not Associated With an Improved Procedure Speed

Objectives: To assess whether performing a pre-intervention gadolinium-enhanced extracranial magnetic resonance angiogram (MRA) in addition to intracranial vascular imaging is associated with improved thrombectomy time metrics. Methods: Consecutive patients treated by MT at a large comprehensive stroke center between January 2012 and December 2017 who were screened using pre-intervention MRI were included. Patients characteristics and procedural data were collected. Univariate and multivariate analysis were performed to compare MT speed, efficacy, complications, and clinical outcomes between patients with and without pre-intervention gadolinium-enhanced extracranial MRA. Results: A total of 912 patients were treated within the study period, including 288 (31.6%) patients with and 624 (68.4%) patients without extracranial MRA. Multivariate analysis showed no significant difference between groups in groin puncture to clot contact time (RR = 0.93 [0.85-1.02], p = 0.14) or to recanalization time (RR = 0.92 [0.83-1.03], p = 0.15), rates of successful recanalization (defined as a mTICI 2b or 3, RR = 0.93 [0.62-1.42], p = 0.74), procedural complications (RR = 0.81 [0.51-1.27], p = 0.36), and good clinical outcome (defined by a mRS ≤ 2 at 3 months follow-up, RR = 1.05 [0.73-1.52], p = 0.79). Conclusion: Performing a pre-intervention gadolinium-enhanced extracranial MRA in addition to non-contrast intracranial MRA at stroke onset does not seem to be associated with a delay or shortening of procedure times.

Hemorrhagic transformation after stroke: inter- and intrarater agreement

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a complication of stroke that can occur spontaneously or after treatment. We aimed to assess the inter- and intrarater reliability of HT diagnosis.

METHODS

Studies assessing the reliability of the European Cooperative Acute Stroke Study (ECASS) classification of HT or of the presence (yes/no) of HT were systematically reviewed. A total of 18 raters independently examined 30 post-thrombectomy computed tomography scans selected from the Aspiration versus STEnt-Retriever (ASTER) trial. They were asked whether there was HT (yes/no), what the ECASS classification of the particular scan (0/HI1/HI2/PH1/PH2) (HI indicates hemorrhagic infarctions and PH indicates parenchymal hematomas) was and whether they would prescribe an antiplatelet agent if it was otherwise indicated. Agreement was measured with Fleiss' and Cohen's κ statistics.

RESULTS

The systematic review yielded four studies involving few (≤3) raters with heterogeneous results. In our 18-rater study, agreement for the presence of HT was moderate [κ = 0.55; 95% confidence interval (CI), 0.41-0.68]. Agreement for ECASS classification was only fair for all five categories, but agreement improved to substantial (κ = 0.72; 95% CI, 0.69-0.75) after dichotomizing the ECASS classification into 0/HI1/HI2/PH1 versus PH2. The inter-rater agreement for the decision to reintroduce antiplatelet therapy was moderate for all raters, but substantial among vascular neurologists (κ = 0.70; 95% CI, 0.57-0.84).

CONCLUSION

The ECASS classification may involve too many categories and the diagnosis of HT may not be easily replicable, except in the presence of a large parenchymal hematoma.

A randomized pragmatic care trial on endovascular acute stroke interventions (EASI): criticisms, responses, and ethics of integrating research and clinical care

BACKGROUND

The Endovascular Acute Stroke Intervention (EASI) trial was conceived as a pragmatic care trial, designed to integrate trial methods with clinical practice. Reporting the EASI experience was met with objections and criticisms during peer review concerning both scientific and ethical issues. Our goal is to discuss these criticisms in order to promote the pragmatic approach of care trials in outcome-based medical care.

METHODS

The comments and criticisms of 11 reviewers from 5 journals were collected and analyzed. The EASI protocol was also compared to the protocols of seven thrombectomy trials using the pragmatic-explanatory continuum indicator summary (PRECIS).

RESULTS

Main criticisms of EASI concerned selection criteria that were judged to be too vague and too inclusive, brain and vascular imaging methods that were not sufficiently prescribed by protocol, lack of blinding of outcome assessment, and lack of power. EASI was at the pragmatic end of the spectrum of thrombectomy trials.

CONCLUSION

The pragmatic care trial methodology is not currently well-established. More work needs to be done to integrate scientific methods and ethical care in the best medical interest of current patients.

Hyperphosphatemic familial tumoral calcinosis secondary to fibroblast growth factor 23 (FGF23) mutation: a report of two affected families and review of the literature

Hyperphosphatemic familial tumoral calcinosis (HFTC), secondary to fibroblast growth factor 23 (FGF23) gene mutation, is a rare genetic disorder characterized by recurrent calcified masses. We describe young Lebanese cousins presenting with HFTC, based on a retrospective chart review and a prospective case study. In addition, we present a comprehensive review on the topic, based on a literature search conducted in PubMed and Google Scholar, in 2014 and updated in December 2017. While the patients had the same previously reported FGF23 gene mutation (homozygous c.G367T variant in exon 3 leading to a missense mutation), they presented with variable severity and age of disease onset (at 4 years in patient 1 and at 23 years in patient 2). A review of the literature revealed several potential patho-physiologic pathways of HFTC clinical manifestations, some of which may be independent of hyperphosphatemia. Most available treatment options aim at reducing serum phosphate level, by stimulating renal excretion or by inhibiting intestinal absorption. HFTC is a challenging disease. While the available medical treatment has a limited and inconsistent effect on disease symptomatology, surgical resection of calcified masses remains the last resort. Research is needed to determine the safety and efficacy of FGF23 replacement or molecular therapy, targeting the specific genetic aberration. Hyperphosphatemic familial tumoral calcinosis is a rare genetic disorder characterized by recurrent calcified masses, in addition to other visceral, skeletal, and vascular manifestations. It remains a very challenging disease.

Agreement between core laboratory and study investigators for imaging scores in a thrombectomy trial

PURPOSE

We aimed to assess the agreement between study investigators and the core laboratory (core lab) of a thrombectomy trial for imaging scores.

METHODS

The Alberta Stroke Program Early CT Score (ASPECTS), the European Collaborative Acute Stroke Study (ECASS) hemorrhagic transformation (HT) classification, and the Thrombolysis In Cerebral Infarction (TICI) scores as recorded by study investigators were compared with the core lab scores in order to assess interrater agreement, using Cohen's unweighted and weighted kappa statistics.

RESULTS

There were frequent discrepancies between study sites and core lab for all the scores. Agreement for ASPECTS and ECASS HT classification was less than substantial, with disagreement occurring in more than one-third of cases. Agreement was higher on MRI-based scores than on CT, and was improved after dichotomization on both CT and MRI. Agreement for TICI scores was moderate (with disagreement occurring in more than 25% of patients), and went above the substantial level (less than 10% disagreement) after dichotomization (TICI 0/1/2a vs 2b/3).

CONCLUSION

Discrepancies between scores assessed by the imaging core lab and those reported by study sites occurred in a significant proportion of patients. Disagreement in the assessment of ASPECTS and day 1 HT scores was more frequent on CT than on MRI. The agreement for the dichotomized TICI score (the trial's primary outcome) was substantial, with less than 10% of disagreement between study sites and core lab.

TRIAL REGISTRATION NUMBER

NCT02523261, Post-results.

DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) Mismatch in Thrombectomy Candidates: An Intrarater and Interrater Agreement Study

BACKGROUND AND PURPOSE

We aimed to study the intrarater and interrater agreement of clinicians attributing DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) mismatch in patients with acute ischemic stroke referred for mechanical thrombectomy.

METHODS

Eighteen raters independently scored anonymized magnetic resonance imaging scans of 30 participants from a multicentre thrombectomy trial, in 2 different reading sessions. Agreement was measured using Fleiss κ and Cohen κ statistics.

RESULTS

Interrater agreement for DWI-ASPECTS was slight (κ=0.17 [0.14-0.21]). Four raters (22.2%) had a substantial (or higher) intrarater agreement. Dichotomization of the DWI-ASPECTS (0-5 versus 6-10 or 0-6 versus 7-10) increased the interrater agreement to a substantial level (κ=0.62 [0.48-0.75] and 0.68 [0.55-0.79], respectively) and more raters reached a substantial (or higher) intrarater agreement (17/18 raters [94.4%]). Interrater agreement for DWI-FLAIR mismatch was moderate (κ=0.43 [0.33-0.57]); 11 raters (61.1%) reached a substantial (or higher) intrarater agreement.

CONCLUSIONS

Agreement between clinicians assessing DWI-ASPECTS and DWI-FLAIR mismatch may not be sufficient to make repeatable clinical decisions in mechanical thrombectomy. The dichotomization of the DWI-ASPECTS (0-5 versus 0-6 or 0-6 versus 7-10) improved interrater and intrarater agreement, however, its relevance for patients selection for mechanical thrombectomy needs to be validated in a randomized trial.

Embolization with larger-caliber coils can increase packing density: Evidence from the pilot phase of a randomized trial

Background and purpose Endovascular coil embolization of cerebral aneurysms is associated with suboptimal angiographic results in up to 20-30% of patients. Coil packing density has been used as an index of the success of the initial procedure. The trial sought to study the effects of using 15-caliber coils, as compared with 10-caliber coils, on packing density. Methods Does Embolization with Larger coils lead to better Treatment of Aneurysms (DELTA) is an investigator-initiated multicenter prospective, randomized, controlled clinical trial. Patients are randomized 1:1 to embolization with either 10-caliber coils exclusively (control group) or the highest safely achievable proportion of 15-caliber coils and 10-caliber coils if necessary (intervention group) in 4-12-mm aneurysms. The endpoint of the pilot phase of the trial was the capacity to increase packing density of the initial procedure, calculated using a mathematical transformation of the dimensions entered into the case report forms. Secondary outcomes included the total number of coils used per aneurysm, total fluoroscopy time, initial angiographic outcomes and any adverse or undesirable event. Results Seventy patients were recruited between June 2014 and November 2015. Compared with 10-caliber coils, the 15-caliber coil group had a higher median packing density (44% vs 24%, p = 0.017). Results of other outcome measures were similar for the two groups. Conclusion Coiling of small and medium aneurysms randomized to 15-caliber coils achieved higher packing densities compared with coiling using 10-caliber coils.

Endovascular treatment of aneurysms and platinum coil caliber: Study protocol of a randomized, controlled trial

BACKGROUND

Endovascular coil embolization of cerebral aneurysms is an effective treatment for the prevention of aneurysm rebleeding after subarachnoid hemorrhage. It is also often used in unruptured aneurysms, but it is associated with aneurysm remnants and recurrences in up to 20%-33% of patients. We hypothesized that better aneurysm occlusion rates can be achieved with coils of larger caliber.

METHODS

The Does Embolization with Larger coils lead to better Treatment of Aneurysms (DELTA) trial is an investigator-initiated, multicenter, prospective, randomized, controlled clinical trial. To test the hypothesis that 15-caliber coiling systems are superior to 10-caliber coils, 564 patients with aneurysms measuring 4-12 mm will be randomized 1:1 to embolization with either 10-caliber coils exclusively (control group) or the highest safely achievable proportion of 15-caliber coils (intervention group). The primary efficacy endpoint of the trial is the occurrence of a major recurrence or a residual aneurysm at one year. A pilot phase of 165 patients will be conducted to verify feasibility of the coiling strategy, compliance to treatment allocation, safety of a 15-caliber platinum coil embolization strategy, recruitment rates, and the capacity to improve packing density.

DISCUSSION

The DELTA trial will test the hypothesis that the use of coils of larger caliber can improve angiographic results of endovascular coiling.

Streamlined Hyperacute Magnetic Resonance Imaging Protocol Identifies Tissue-Type Plasminogen Activator-Eligible Stroke Patients When Clinical Impression Is Stroke Mimic

BACKGROUND AND PURPOSE

Stroke mimics (SM) challenge the initial assessment of patients presenting with possible acute ischemic stroke (AIS). When SM is considered likely, intravenous tissue-type plasminogen activator (tPA) may be withheld, risking an opportunity to treat AIS. Although computed tomography is routinely used for tPA decision making, magnetic resonance imaging (MRI) may diagnose AIS when SM is favored but not certain. We hypothesized that a hyperacute MRI (hMRI) protocol would identify tPA-eligible AIS patients among those initially favored to have SM.

METHODS

A streamlined hMRI protocol was designed based on barriers to rapid patient transport, MRI acquisition, and post-MRI tPA delivery. Neurologists were trained to order hMRI when SM was favored and tPA was being withheld. The use of hMRI for tPA decision making, door-to-needle times, and outcomes were compared before hMRI implementation (pre-hMRI: August 1, 2011 to July 31, 2013) and after (post-hMRI, August 1, 2013, to January 15, 2015).

RESULTS

Post hMRI, 57 patients with suspected SM underwent hMRI (median MRI-order-to-start time, 29 minutes), of whom, 11 (19%) were diagnosed with AIS and 7 (12%) received tPA. Pre-hMRI, no tPA-treated patients were screened with hMRI. Post hMRI, 7 of 106 (6.6%) tPA-treated patients underwent hMRI to aid in decision making because of suspected SM (0% versus 6.6%; P=0.001). To ensure standard care was maintained after implementing the hMRI protocol, pre- versus post-hMRI tPA-treated cohorts were compared and did not differ: door-to-needle time (39 versus 37 minutes; P=0.63), symptomatic hemorrhage rate (4.5% versus 1.9%; P=0.32), and favorable discharge location (85% versus 89%; P=0.37).

CONCLUSIONS

A streamlined hMRI protocol permitted tPA administration to a small, but significant, subset of AIS patients initially considered to have SM.

Abstract 162: Sustained Improvement of Door-to-Needle Times Using Toyota's LEAN Manufacturing Principles: The Washington University Experience 2003-15

Background and Purpose: Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke (AIS), demonstrated by fast door-to-needle times (DNTs), leads to improved patient outcomes. Discrete interventions can improve DNTs, but often this improvement is not sustained over the long term.

Hypothesis: LEAN quality improvement methodology can sustain and improve DNTs over a course of decade.

Methods: Since 2003, a multidisciplinary quality improvement team has been continually monitoring and modifying the tPA protocol to eliminate inefficiencies using LEAN tools such as value stream analysis or rapid improvement events. We report our quality metrics (DNT, onset-to-treatment time (ONT), NIHSS, symptomatic intracranial hemorrhage (sICH) and favorable discharge clinical outcomes) as they relate to specific LEAN events.

Results: Over a 10-year period, process improvement events have dramatically accelerated DTN times for AIS patients in a single hospital ED. The first event in 2004 (resident-based protocol) led to 25% improved DNT (81 vs. 60, P<0.001). In 2011, a new protocol (routing patients directly to CT, using parallel process workflow, and point-of-care labs) improved DNTs 35% (60 vs. 39 minutes, P<0.0001). Finally, in 2014 a treat-in-CT protocol was adopted and lowered DNTs 24% (38 vs. 29 min, P=0.002), for overall 58% improvement in DTN since 2004 (P<0.0001). To ensure efficiency gained was not at the expense of patient safety, sICH, favorable discharge location and percentage of stroke mimics (available only since 2011) were compared and did not differ over time.

Conclusions: Application of LEAN and ongoing process improvement measures led to sustained improvement in DNTs for over a decade without compromising safety.

Defining the ischemic penumbra using magnetic resonance oxygen metabolic index

BACKGROUND AND PURPOSE

Penumbral biomarkers promise to individualize treatment windows in acute ischemic stroke. We used a novel magnetic resonance imaging approach that measures oxygen metabolic index (OMI), a parameter closely related to positron emission tomography-derived cerebral metabolic rate of oxygen utilization (CMRO2), to derive a pair of ischemic thresholds: (1) an irreversible-injury threshold that differentiates ischemic core from penumbra and (2) a reversible-injury threshold that differentiates penumbra from tissue not-at-risk for infarction.

METHODS

Forty patients with acute ischemic stroke underwent magnetic resonance imaging at 3 time points after stroke onset: <4.5 hours (for OMI threshold derivation), 6 hours (to determine reperfusion status), and 1 month (for infarct probability determination). A dynamic susceptibility contrast method measured cerebral blood flow, and an asymmetrical spin echo sequence measured oxygen extraction fraction, to derive OMI (OMI=cerebral blood flow×oxygen extraction fraction). Putative ischemic threshold pairs were iteratively tested using a computation-intensive method to derive infarct probabilities in 3 tissue groups defined by the thresholds (core, penumbra, and not-at-risk tissue). An optimal threshold pair was chosen based on its ability to predict infarction in the core, reperfusion-dependent survival in the penumbra, and survival in not-at-risk tissue. The predictive abilities of the thresholds were then tested within the same cohort using a 10-fold cross-validation method.

RESULTS

The optimal OMI ischemic thresholds were found to be 0.28 and 0.42 of normal values in the contralateral hemisphere. Using the 10-fold cross-validation method, median infarct probabilities were 90.6% for core, 89.7% for nonreperfused penumbra, 9.95% for reperfused penumbra, and 6.28% for not-at-risk tissue.

CONCLUSIONS

OMI thresholds, derived using voxel-based, reperfusion-dependent infarct probabilities, delineated the ischemic penumbra with high predictive ability. These thresholds will require confirmation in an independent patient sample.

Abstract W P32: CSF Volumetric Analysis Reliably Quantifies Cerebral Edema And Correlates With Clinical Deterioration In Large Hemispheric Infarcts

Background: Large hemispheric infarcts (LHI) may be complicated by cerebral edema. Midline shift (MLS), a standard radiographic measure, only crudely estimates extent of edema. Volumetric analysis of CSF compartments over time may provide a reliable and accurate means of quantifying severity and kinetics of edema after LHI.

Methods: We retrospectively identified stroke patients with NIHSS≥8 and baseline CT within 6 hours who developed cerebral edema (without hemorrhage) on follow-up (FU) CTs. Two raters outlined the sulci and lateral ventricles ipsilateral (IL) and contralateral (CL) to the infarct on baseline and serial FU CTs (both within 48 hours and at peak edema, 2-5 days post-stroke) and quantified CSF and infarct volumes. Changes in compartment volumes from baseline to peak edema CT were correlated with MLS and edema-related neurologic worsening (need for hemicraniectomy, osmotic therapy, or decline in GCS, associated with MLS≥5mm).

Results: Ten patients were analyzed (median NIHSS 14, time to early FU CT 30 hours, IQR 15-37 and to peak edema CT 75 hours, IQR 64-95). Inter-rater reliability for volume measures was excellent (intraclass correlation >0.97). CSF volume diminished by 37±20% (49 ml) from baseline to peak edema, over half occurring within 48 hours; net decline in CSF volume correlated with infarct volume (r=-0.63,p=0.05). Greatest reductions in CSF were seen in IL sulci and IL ventricles (Figure, top), but it was % reduction in CL sulci that correlated best with MLS (Fig, bottom), even adjusting for infarct volume (p=0.02). Decline in volumes of IL and CL sulci were greater in the 5 subjects with neurological worsening (89% vs. 56% and 40% vs. 3%, p<0.05), while infarct volume was not.

Conclusions: CSF volumetrics is a reliable tool for quantifying cerebral edema after LHI and a novel method of studying edema kinetics. Loss of sulcal volume correlates with MLS and is more strongly associated with edema-related deterioration than infarct volume alone.

Abstract T P72: Baseline Variables Have Little Influence on Early Change in Neurological Status (ΔNIHSS) After Acute Ischemic Stroke: Basis For a Genetic Study

Introduction: Neurological deficits can be highly unstable within the first 24 hours after acute ischemic stroke (AIS), with some patients showing dramatic improvement while others rapidly deteriorate. We are interested in genetic influences on early neurological recovery/deterioration. Here, we characterize NIHSS changes within the first 24 hours after stoke onset (ΔNIHSS) in a large cohort to determine baseline clinical variables that influence this outcome measure.

Methods: AIS patients presenting to two sites (Barnes-Jewish Hospital, St Louis and Vall D’Hebron Hospital Barcelona) between 2008-2013 were prospectively enrolled. Baseline NIHSS was collected within 6 hours and again at 24 hours after symptom onset. ΔNIHSS was calculated as the difference in these stroke scale scores. Demographics, baseline comorbidities and medications, as well as acute treatment variables were recorded for each subject. Stepwise multivariable regression (SAS) was used to determine variables that significantly influence ΔNIHSS.

Results: There were 954 patients enrolled (St Louis = 433, Barcelona = 521). Table 1 demonstrates the frequencies and means (SD) of the baseline variables. ΔNIHSS follows a normal distribution (figure). All baseline variables listed in table 1 were analyzed for influence on ΔNIHSS. Only baseline NIHSS (R2 = 0.0597, p<0.0001), baseline glucose (R2 = 0.0176, p=<0.0001,) and age (R2 = 0.0106, p=0.0011) independently influenced ΔNIHSS, accounting for only 8.79% of the variance.

Conclusion: Baseline variables (NIHSS, glucose and age) modestly influence early neurological recovery/deterioration. However, 91% of ΔNIHSS variability remains unexplained, suggesting that other factors such as genetics, could play an important role in early outcomes following AIS. A GWAS of ΔNIHSS is currently underway.

Abstract W P317: Early CSF Volume Changes Predict Malignant Edema in Large Hemispheric Infarction

Background: Early clinical and radiographic measures (such as NIHSS or early CT hypodensity) incompletely predict which patients with hemispheric stroke will develop malignant cerebral edema. We evaluated whether quantitative changes in volume of CSF compartments on early follow-up (FU) CT predict peak radiographic edema and clinical worsening.

Methods: We retrospectively identified patients with hemispheric infarcts, NIHSS≥8, baseline CT within 6 hours of stroke onset and FU CT within 48 hours (i.e. prior to development of maximal edema). Volumes of CSF in ipsilateral (IL) and contralateral (CL) sulci and lateral ventricles were manually outlined on both scans, as was infarct volume on FU CT. Midline shift (MLS) was measured on later CT at time of peak edema (if available). Reduction in CSF compartments from baseline and symmetry (IL:CL ratios) were correlated to peak MLS and edema-related clinical deterioration (need for hemicraniectomy, osmotic therapy, or GCS decline, with MLS>5mm).

Results: Ten patients were analyzed (median NIHSS 13, FU CT at median of 30 hours, IQR 15-37). Sulcal asymmetry (ratio of IL:CL volume) on FU CT was greater in the 4 subjects who deteriorated from malignant edema (median 0.26 vs. 0.79, see Figure), as was % reduction in IL sulcal volume from baseline (76% vs. 35%, p=0.06), while volume of early infarct was not. Hemispheric CSF asymmetry and % reduction in IL ventricular volume at early FU CT were strongly correlated with peak MLS (r=-0.95 and -0.96, both p=0.01). Linear regression found that both early infarct volume and % reduction in IL ventricle volume were strongly associated with MLS, adjusting for baseline CSF volume (Betas 0.55 and -0.48, both p=0.001).

Conclusions: In this preliminary study, early CSF asymmetry and reduction in IL CSF volumes appear to predict development of MLS and malignant edema. Further validation is needed to test whether CSF volumetrics have utility in selection of patients for early aggressive interventions.

Coeliac disease presenting as severe hypoglycaemia in youth with type 1 diabetes

BACKGROUND

Coeliac disease is an autoimmune disorder classically characterized by gastrointestinal symptoms and poor growth. The disease can be difficult to recognize in patients with Type 1 diabetes mellitus. Some clinicians find treatment of the disease in asymptomatic individuals controversial.

CASE REPORTS

Two adolescent female patients with Type 1 diabetes experienced recurrent hypoglycaemic seizures. Neither patient reported gastrointestinal symptoms or poor growth. After diagnosis and treatment of coeliac disease, hypoglycaemia resolved.

CONCLUSION

These cases illustrate how frequent unexplained severe hypoglycaemia can be an atypical presentation of coeliac disease in youth with Type 1 diabetes. Furthermore, they emphasize the importance of screening and treatment of coeliac disease in asymptomatic patients with Type 1 diabetes. Although controversial, management of coeliac disease in these asymptomatic patients can prevent the vicious cycle of recurrent hypoglycaemia and decrease risk for morbidity and death.

Abstract 76: Genome Wide Association Study of Early Neurological Deterioration after Acute Ischemic Stroke Defines the Interferon-Stimulated Gene IFIT1 as a Neuroprotective Factor

Introduction: In the first hours after ischemic stroke, neurological deficits can be highly unstable. These early neurological changes are important due to their influence on long-term outcome. We performed a GWAS on ΔNIHSS 24h (NIHSS change from baseline to 24 hours after stroke onset) in acute ischemic stroke patients.

Methods: DNA from 191 stroke patients presenting within 4.5 hours of stroke onset was genotyped using an Affymetrix Exome-chip. Single variant analysis was performed using PLINK, including age, baseline NIHSS and principal component factors as covariates. European- and African-Americans were analyzed separately, with p-values combined by meta-analysis. Gene-based analysis was performed using SKAT-O, including only non-synonymous variants. Pathway analysis was performed using ALIGATOR to identify pathways with SNPs with significant associations. IFIT1 -/- and IFIT1 +/+ mice underwent one-hour MCA occlusion (tMCAO) followed by 24-hour reperfusion. Brains were removed, TTC-stained, and infarcts measured.

Results: Single variant analysis did not reveal genome-wide significant associations. One gene, IFIT1 (interferon-induced protein with tetratricopeptide repeats), passed the gene-based genome-wide multiple test correction (A). All three polymorphic variants in IFIT1 associated with neurologic deterioration with an average ΔNIHSS 24h 9.5 points lower in carriers versus non-carriers (B). Pathway analysis, including 21 interferon-related genes but excluding IFIT1 , showed a highly significant association (p=2.30х10 -3 ) with ΔNIHSS 24h. Infarct volumes in IFIT1 -/- mice were twice the size of IFIT1 +/+ mice after tMCAO (C, 110.6 mm 3 vs 52.8 mm 3 ).

Conclusion: These data suggest that IFIT1 and other interferon-related genes may function in endogenous neuroprotective responses during acute ischemic stroke.

Abstract W P38: Rates of ADC and Flair Signal Maturation Depend on Depth of Ischemia and Time: Helpful for Determining Time of Onset?

Background: Imaging biomarkers may be useful to estimate time of stroke onset when it is unknown. We studied FLAIR and ADC signal maturation in acute ischemic stroke patients to understand how the severity of ischemia may influence the rate of signal change.

Methods: Ischemic stroke patients with witnessed onset were sequentially imaged with FLAIR, ADC, and PWI (MTT) at 3, 6, and 24 hr after onset. FLAIR and ADC signal intensity (SI) was normalized to the contralesional hemisphere (nFLAIR and nADC). White matter disease was excluded. Regions of stable ischemia between 3-6hr and 6-24hr were stratified based on 6 increments of MTT prolongation (pMTT) ranging from mild to severe ischemia. Rates of nFLAIR and nADC change between 2 time-points (units= /hr and x10-6 mm2/s /hr, respectively) were measured between 3-6hr and 6-24hr for each pMTT increment. % of patients with FLAIR positivity (defined as nFLAIR > 1.15) at 3 and 6 hr was calculated for each pMTT increment.

Results: 37 patients were imaged at 2.6, 6.2, and 24 hr after stroke onset. Between 3 and 6 hr (Fig A, blue), rates of SI change for nFLAIR and nADC progressively increased with increasing severity of ischemia (p<0.0001; Kruskal-Willis). Between 6 and 24 hr (Fig A, green), nFLAIR rates of change decreased but continued to depend on ischemic severity, (p=0.0002). However, during this later time period nADC did not change with ischemic severity (p=0.36). The % of patients with FLAIR positivity increased between 3 and 6 hr and with increasing severity of ischemia (p=0.34 and p=0.0003, respectively; Chi-Square); Fig B.

Conclusions: Rates of FLAIR and ADC change and FLAIR positivity were influenced by time from stroke onset and severity of ischemia. While FLAIR signal continued to demonstrate perfusion-dependent change beyond 6 hrs, ADC signal matured at 6 hrs, showing little change beyond. Understanding the factors influencing rates of FLAIR and ADC change may help refine an imaging biomarker for determining the time of stroke onset.

Abstract TP244: Distinguishing Stroke Mimics From Strokes Prior To Treatment With tPA

Introduction: Up to 25% of patients treated with IV tPA are later found to have stroke mimics. Despite low rates of hemorrhagic transformation in these patients, avoiding exposure to unnecessary risk is desirable. Here, we define baseline demographic and clinical characteristics of strokes vs. stroke mimics that might help distinguish these two populations prior to treatment decisions.

Methods: All patients treated with IV tPA at our tertiary care academic medical center are registered in a prospectively maintained database. Consecutive patients from 1/09 to 6/12 were entered in this study. Demographic, historical, and neuro exam findings (20 variables) from stroke or stroke mimic patients (based on the discharge diagnosis) were examined. Spearman correlations and binary logistic regression were used to determine variables contributing to mimic status. Post-hoc correlations of individual NIHSS items with mimic status were examined.

Results: During this period, 346 patients were treated with IV tPA of which 38 (11%) were stroke mimics. Logistic regression revealed that age (B = -0.61, p < 0.001), history of drug use (B = 1.508, p <0.05), and acute NIHSS facial score (B = -1.12, p < 0.01) significantly predicted mimic status. Sex (B = -1.043, p = .066) and “drip and ship” status (B = 1.04, p = .063) were marginal predictors, whereas history of depression, epilepsy, and number of ED visits in the past 5 years failed to predict mimic status. The logistic regression equation accounted for 39% of the variance in mimic status. Post-hoc Spearman correlations of NIHSS categories with mimic status found that total score ( r = -0.16), visual field loss ( r = -0.16), gaze deviation ( r = -0.21), facial weakness (r = -0.22), dysarthria (r = -0.19), and neglect ( r = -0.18) were all variables significantly associated with acute stroke.

Conclusion: Younger age, female gender, history of drug use, and treatment at outlying facility (drip and ship) were associated with stroke mimics. NIHSS categories associated with acute stroke were visual field loss, gaze deviation, facial droop, dysarthria and neglect. Identifying baseline variables that help distinguish mimics may minimize inappropriate treatment with tPA.

Abstract TP336: Sustaining Excellence in Alteplase Administration in the Emergency Department: Staying Lean

Background: Identification and treatment of acute ischemic stroke (AIS) patients in the emergency department (ED) was reorganized in January 2011 using Lean Methodologies. The team achieved initial success post implementation in March 2011 of median time to treatment of 34 minutes. Sustaining the improvements required a shift in paradigm of the ED Acute Stroke Committee (EDASC) and the front line staff caring for the patients. Pre-Lean door to treatment time was 60 minutes (N=132).

Methods: Lean methodologies were chosen as a process improvement strategy. Initial implementation demonstrated immediate success of reaching 34 minutes; however in the first quarter following the implementation, the team identified drift in the process and increased numbers of stroke activation evaluations. Individual case review at monthly meetings demonstrated intermittent role confusion, complex patient presentations, inconsistency in process for alteplase preparation and patient preparation. While the team historically discussed these issues, the expectations had been raised to sustain the critical changes. Identification of individuals in each case for role clarification, general nursing education regarding alteplase preparation, reinforcement of bolus administration as a priority and the addition of point of care testing to decrease barriers enabled the front line staff to receive timely feedback and rapid practice corrections.

Results: The initial protocol changes were implemented in March 2011. Team reviews with rapid (less than 48 hour) feedback were implemented in April 2011. Point of care testing was implemented in September 2011 for PT/INR testing. Median time to treatment increased to 51 and 48 minutes in April and May 2011. Through drill down review, communication of expectations and progress, and addition of point of care testing the post implementation median time is currently 39 minutes (N=120) for 2011 and 2012.

Conclusions: Rapid process improvement using lean tools creates opportunities to radically alter a process of care. Sustaining the changes requires rapid attention to process defects, identification of additional opportunities for improvement and individual accountability to the process.

Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis

BACKGROUND AND PURPOSE

Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy, prompting national efforts to reduce door-to-needle times. We used lean process improvement methodology to develop a streamlined intravenous tPA protocol.

METHODS

In early 2011, a multidisciplinary team analyzed the steps required to treat patients with acute ischemic stroke with intravenous tPA using value stream analysis (VSA). We directly compared the tPA-treated patients in the "pre-VSA" epoch with the "post-VSA" epoch with regard to baseline characteristics, protocol metrics, and clinical outcomes.

RESULTS

The VSA revealed several tPA protocol inefficiencies: routing of patients to room, then to CT, then back to the room; serial processing of workflow; and delays in waiting for laboratory results. On March 1, 2011, a new protocol incorporated changes to minimize delays: routing patients directly to head CT before the patient room, using parallel process workflow, and implementing point-of-care laboratories. In the pre and post-VSA epochs, 132 and 87 patients were treated with intravenous tPA, respectively. Compared with pre-VSA, door-to-needle times and percent of patients treated ≤60 minutes from hospital arrival were improved in the post-VSA epoch: 60 minutes versus 39 minutes (P<0.0001) and 52% versus 78% (P<0.0001), respectively, with no change in symptomatic hemorrhage rate.

CONCLUSIONS

Lean process improvement methodology can expedite time-dependent stroke care without compromising safety.

Abstract 2497: Achieving Door-to-Needle Times of 37 minutes using a Streamlined Resident-Based Acute Stroke Protocol

Background: While tPA efficacy is enhanced by shorter delivery times, a recent analysis of the National Get-With-the-Guidelines stroke data demonstrated that only 29% of patients receive tPA < 60 min from hospital arrival. To further improve door-to-needle (DTN) times (time from patient arrival to time of tPA administration) within our resident-driven stroke protocol, we carefully reviewed our process to identify inefficiencies, leading to a revised protocol. We tested the efficiency and safety of the new, streamlined protocol comparing protocol metrics, symptomatic hemorrhage rates, and discharge outcomes before and after the changes.

Methods: In early 2011, a value stream analysis (VSA) was conducted, identifying several inefficiencies within our tPA protocol which included: (1) routing of patients to room, then CT, then back to room; (2) serial processing of work flow; and (3) delays in waiting for labs. On 3/1/11, a new resident-driven protocol was adopted incorporating changes to minimize delays: (1) routing patients directly to head CT prior to patient room, (2) utilizing a parallel approach to process work flow, and (3) implementing point-of-care (POC) labs. We directly compared the “Pre-VSA” epoch (1/1/09-2/28/11) to the “Post-VSA” epoch (3/1/11-7/31/11) with regard to baseline variables, protocol metrics, and discharge outcomes. Wilcoxon Rank Sum test was used for continuous data and Fisher’s Exact test was used for binary data with p<.05 required for significance.

Results: In the Pre-VSA epoch, 132 patients were treated with IV tPA (0-4.5hr window). In the Post-VSA epoch, 37 patients were treated with IV tPA. Baseline variables such as age, NIH Stroke Scale, and past medical history were similar between the 2 epochs except for greater proportion of African-Americans and hypertension in the Post-VSA epoch ( Table ). Median DTN and onset-to-needle times were lower in the Post-VSA epoch: 60 min pre-VSA vs. 37 min post-VSA (p<0.0001) and 131 vs. 102 min. (p=0.056, strong trend), respectively. Of the remaining metrics, door-to-CT time differed between the 2 epochs (16 min vs. 1 min, p<0.0001). To ensure that efficiency was not gained at the cost of patient safety, “Favorable” discharge location (discharge to home or inpatient rehabilitation), symptomatic hemorrhage rate, and percentage of stroke mimics (patients with non-stroke diagnosis at discharge) were compared and did not differ between the two groups ( Table ).

Conclusions: A resident-based stroke protocol using efficient choreography, parallel processing, and POC labs can accelerate tPA delivery without compromising patient safety.

Morphological and biochemical alterations in the jejunum following iodoacetamide-induced colitis in rats

This study aims to describe the morphological alterations in the small and large intestines as well as the expression of some enterocyte enzymes and carriers in a rat model of iodoacetamide-induced colitis. Biopsies from the large and small intestines were taken at 1, 2, 4, 8, and 16 days postinduction and studied by light microscopy. The expressions of lactase, sucrase, aminopeptidase, and Glut-5 in the jejunum were studied by immunohistochemistry. Gene expressions of enterocyte lactase and sucrase were determined by RT-PCR using specific oligonucleotides. Microscopic examination of the large intestines revealed manifestations concordant with inflammation. Such alterations peaked at 2 days, were maintained to a lesser extent for 4 days, regressed by 8 days, and healed by 16 days. In the jejunum, the expression of lactase, sucrase, and aminopeptidase decreased 2 days after colitis induction, and recovered 2 days later. Similarly, Glut-5 expression decreased transiently with partial recovery by day 8. Compared with sham, gene expression of jejunal brush border enzymes sucrase and lactase showed a 4-fold increase in lactase and a 9-fold increase in sucrase after 4 days. We conclude that colitis can induce significant functional abnormalities in distant noninflamed small bowel regions.

[A case of alcohol-induced ketoacidosis?]

We report a case of severe ketoacidosis. Initially the patient showed metabolic acidosis, the anion gap was positive and there was neither hyperlactatemia nor intoxication with acid substances. As the rate of glycemia was high (17.8 mmol/L), the diagnosis of diabetic ketoacidosis was proposed. Under treatment with continuous IV injection of insulin, hypoglycemia (1.8 mmol/L) appeared rapidly, while urine bioreactive test was positive for ketonuria, but negative for glycosuria. We finally concluded that it was an alcoholic ketoacidosis. The history of the patient confirmed the diagnosis : chronic alcoholism with recent increased of alcohol intake which provoked vomiting and fasting. This case report shows the difficulty in distinguishing between alcoholic ketoacidosis and diabetic ketoacidosis. We discuss the diagnostic strategy and particularly biologic data in the light of pathophysiologic mechanism of alcoholic ketoacidosis.

Frequency of the CCR5-delta 32 chemokine receptor gene mutation in the Lebanese population

A direct correlation between HIV infection and mutation in the chemokine receptor [CCR5] gene has been established. However, such correlation has never been investigated in Lebanon. We report the frequency of the CCR5-delta 32 mutation in a r and om sample of 209 healthy, HIV-1 seronegative Lebanese aged 19-68. Overall, 4.8% were heterozygous for the mutation. Homozygosity was absent from our sample. The frequency for the CCR5-delta 32 allele was 2.5%. Distribution of the mutation was unaffected by sex, age, religion or educational level. The frequency in the Lebanese population is consistent with that in the origin of the mutation in northern Europe. This could be attributed to a gene flow into the Middle East from northern Europe

Frequency of the CCR5-delta 32 chemokine receptor gene mutation in the Lebanese population

A direct correlation between HIV infection and mutation in the chemokine receptor (CCR5) gene has been established. However, such correlation has never been investigated in Lebanon. We report the frequency of the CCR5-delta 32 mutation in a random sample of 209 healthy, HIV-1 seronegative Lebanese aged 19-68. Overall, 4.8% were heterozygous for the mutation. Homozygosity was absent from our sample. The frequency for the CCR5-delta 32 allele was 2.5%. Distribution of the mutation was unaffected by sex, age, religion or educational level. The frequency in the Lebanese population is consistent with that in the origin of the mutation in northern Europe. This could be attributed to a gene flow into the Middle East from northern Europe.

Hypercalcemia in Langerhans' cell granulomatosis with elevated 1,25 dihydroxyvitamin D (calcitriol) level

A 48-year-old woman presented with a history of premature menopause, polyuria, polydipsia, fever, and diffuse bony tenderness. Her evaluation revealed central diabetes insipidus, hypothalamic amenorrhea, an elevated free calcium on multiple occasions with an elevated 1,25 dihydroxyvitamin D level, and osteoporosis by densitometry. Skeletal series revealed multiple lytic lesions involving the long bones. The diagnosis of Langerhans' cell granulomatosis was made. She was treated with hormone replacement therapy, radiotherapy, and vinblastine, with a dramatic improvement in her pain and a near normalization of her free calcium. Whereas hypercalcemia has been described in several granulomatous disorders and is secondary to unregulated extrarenal production of 1,25 dihydroxyvitamin D, it is, however, extremely rare in Langerhans' cell granulomatosis. This is the first case report of Langerhans' cell granulomatosis with hypercalcemia and documented elevated increased 1,25 dihydroxyvitamin D level that responded to the treatment of her primary disease.

[Diffuse colitis associated with mycophenolate mofetil treatment: apropos of 1 case]

Mycophénolate mofétil (MMF) or Cellcept is a potent immunosuppressor that inhibits purin synthesis used to prevent human allograft rejection. The most important secondary effects include haematological and intestinal disorders. Among them, diarrhea is the most common. It is dose-dependant and appears commonly during the first 2 months of treatment. Its physiopathology remains unclear. We reported a case of colitis, 6 months after a kidney transplantation. The patient was treated since day 2 with 2 grams per day of MMF. Morphological analysis showed a diffuse colitis from the coecum to the rectum. Histological samples confirmed a colitis with atrophic crypts but with mucosal secretions and some cryptic abscesses. No granuloma or CMV inclusion was founded. Histochemical immunostaining for CMV was negative. Finally, symptoms regressed within 5 days after tapering down MMF dose in association with metronidazole treatment. The role of MMF in inducing colitis is discussed.