Impact of Muscle Mass as a Prognostic Factor for Failed Waiting Time Prior to Heart Transplantation

Objectives: Clinical deterioration during the waiting time impairs the prognosis of patients listed for heart transplantation. Reduced muscle mass increases the risk for mortality after cardiac surgery, but its impact on resilience against deterioration during the waiting time remains unclear.Methods: We retrospectively analyzed data from 93 patients without a VAD who were listed in Eurotransplant status “high urgent (HU)” for heart transplantation between January 2015 and October 2020. The axial muscle area of the erector spinae muscles at the level of thoracic vertebra 12 indexed to body surface area (TMESA/BSA) measured in the preoperative thoracic computed tomography scan was used to measure muscle mass.Results: Forty patients (43%) underwent emergency VAD implantation during the waiting time and four patients (4%) died during the waiting time. The risk of emergency VAD implantation/death during the waiting time decreased by 10% for every cm2/m2 increase in muscle area [OR 0.901 (95% CI: 0.808–0.996); p = 0.049]. After adjusting for gender [OR 0.318 (95% CI: 0.087–1.073); p = 0.072], mean pulmonary artery pressure [OR 1.061 (95% CI: 0.999–1.131); p = 0.060], C-reactive protein [OR 1.352 (95% CI: 0.986–2.027); p = 0.096], and hemoglobin [OR 0.862 (95% CI: 0.618–1.177); p = 0.360], TMESA/BSA [OR 0.815 (95% CI: 0.698–0.936); p = 0.006] remained an independent risk factor for emergency VAD implantation/death during the HU waiting time.Conclusion: Muscle area of the erector spinae muscle appears to be a potential, easily identifiable risk factor for emergency VAD implantation or death in patients on the HU waiting list for heart transplantation. Identifying patients at risk could help optimize the outcome and the timing of VAD support.

Bilateral Corneal Ghost Vessels in an Otherwise Healthy Child

We report a rare case of bilateral corneal ghost vessels in a 6–year-old child with an unremarkable past ocular and past medical history. This study was a single observational case report. A 6-year-old girl was referred to our clinic for further evaluation, due to suboptimal visual acuity in both eyes. Her past medical and ocular history revealed no systemic, inflammatory, infectious, or degenerative disorders. Slit-lamp examination revealed regressed blood vessels (“ghost vessels”) in the anterior and mid-corneal stroma as the only pathologic finding. Confocal scanning microscopy of both corneas demonstrated scattered branching railroad-shaped ghost vessels at the level of the middle and anterior stroma. Complete systemic workup was performed for the patient. No identifiable risk factor for the development of corneal vascularization was found. According to our findings, we assume that in our patient, vasculogenesis occurred due to angioblast invasion to the presumptive cornea due to disequilibrium in mechanisms involved in vascular patterning during embryonic development.

Immunotherapy experience in malignant pleural mesothelioma in a single tertiary center.

e20565 Background: Malignant pleural mesothelioma (MPM) is a rare and aggressive cancer. Prognosis is generally poor, with a median overall survival (mOS) of approximately 12 months. MPM appears to be directly linked to immunosuppressive mechanisms, leading to use of checkpoint inhibitors for patients with this disease. Methods: We performed a retrospective chart review of patients with MPM at our institution between January 2015 to December 2020. All patients were over 18 years at the time of diagnosis of mesothelioma, a total of 8 patients were retrieved from the pathology database of The American British Cowdray Medical Center. The clinical-pathologic features collected were sex, age, performance status, risk factors, pTNM stage (AJCC 8th edition), histology type, sintomatology of onset, metastases sites and treatment. Clinical response rate and other outcomes were assessed. Descriptive statistics were used to describe a patient's demographic and disease characteristics. Results: 8 patients, aged 49 to 71 years (median of 65) at diagnosis of MPM were treated in our center. Both sex presented 4 patients in total. An identifiable risk factor was recorded in 4 patients (2 with asbesto exposure and 2 with heavy smoking). 7 patients (87.5%) had PS 0 or 1, the remaining has PS 2. The clinical stage at diagnosis was unresectable in 7 patients. 3 patients were assessed with PD-L1 expression (SP263 or 22C3), only one with expression of 20%. All patients received at least one scheme of chemotherapy prior to receiving immunotherapy, 25% received bevacizumab/platinum/anti-folate agents. Checkpoint inhibitors were introduced as a second line in 20% and in 80% has a third or more lines. Pembrolizumab was used in 20% and Nivolumab in 80%. The tumor responses with immunotherapy were as follows: partial response 12.5%, stable disease 75% and progressive disease 12.5%. Median progression-free survival of the first line treatment was 18.9 months (4.6-33.6 months), and for the line with checkpoint inhibitors was 11.2 weeks (7-21.2). In the full cohort, mOS was 37.0 months (95% CI:14.5-39.6). According to histology, the mOS for epithelioid-type was 36.6 months and for biphasic-type was 14.6 months (p = 0.42). mOS was 37.0 months for the group with immunotherapy and 15.0 months for those with standard chemotherapy (p = 0.14). The most frequently reported immune mediated adverse events were hypothyroidism and colitis (each one with one patient). Conclusions: In this real-world analysis, mOS was superior to those obtained in the MAPS2 trial (mOS 11.9 months), despite the fact that 80% of the population that received immunotherapy was in third or more lines. Limitations include limited numbers of patients, retrospective review, single institution, and inclusión of many heavily pretreated patients. Also molecular and immunohistochemical results such as PD-L1 status were only available on a limited number of patients.

Whole genome methylation and transcriptome analyses to identify risk for cerebral palsy (CP) in extremely low gestational age neonates (ELGAN)

Preterm birth remains the leading identifiable risk factor for cerebral palsy (CP), a devastating form of motor impairment due to developmental brain injury occurring around the time of birth. We performed genome wide methylation and whole transcriptome analyses to elucidate the early pathogenesis of CP in extremely low gestational age neonates (ELGANs). We evaluated peripheral blood cell specimens collected during a randomized trial of erythropoietin for neuroprotection in the ELGAN (PENUT Trial, NCT# 01378273). DNA methylation data were generated from 94 PENUT subjects (n = 47 CP vs. n = 47 Control) on day 1 and 14 of life. Gene expression data were generated from a subset of 56 subjects. Only one differentially methylated region was identified for the day 1 to 14 change between CP versus no CP, without evidence for differential gene expression of the associated gene RNA Pseudouridine Synthase Domain Containing 2. iPathwayGuide meta-analyses identified a relevant upregulation of JAK1 expression in the setting of decreased methylation that was observed in control subjects but not CP subjects. Evaluation of whole transcriptome data identified several top pathways of potential clinical relevance including thermogenesis, ferroptossis, ribosomal activity and other neurodegenerative conditions that differentiated CP from controls.

Liver Imaging and Data System (LI-RADS) Version 2018 and Other Imaging Features in Intrahepatic Cholangiocarcinoma in Chinese Adults with vs. without Chronic Hepatitis B Viral Infection

Purpose. To describe liver imaging reporting and data system (LI-RADS) version 2018 and other MRI imaging features in intrahepatic mass-forming cholangiocarcinoma (iCCA) in Chinese adults with vs. without chronic hepatitis B viral (HBV) infection. Methods. We retrospectively enrolled 89 patients with pathologically proven iCCA after multiphase imaging performed between 2004 and 2017 at a tertiary medical center in southern China. Based on whether patients had chronic HBV, iCCA was divided into two subgroups: HBV-positive (n = 50 patients, including 9 with cirrhosis) vs. HBV-negative (n = 39 patients, including 14 with hepatolithiasis and 25 with no identifiable risk factor for iCCA; none had cirrhosis). Two independent abdominal radiologists in consensus reviewed the largest mass in each patient to assign LI-RADS v2018 features; they also scored each observation’s shape and location. Imaging features were compared using chi-square or Fisher’s exact tests. Results. Most iCCAs in HBV-positive (88% (44/50)) and HBV-negative (97% (38/39)) patients had at least one LR-M feature. Compared to iCCAs in HBV-negative patients, iCCAs in HBV-positive patients were more likely to have at least one major feature of HCC (46% (23/50) vs. 8% (3/39), P < 0.001) and more likely to be smooth (42% (21/50) vs. 10% (4/39), P = 0.001). Six of 50 (12%) iCCAs in HBV-positive patients and 1/39 (3%) iCCAs in HBV-negative patients had at least one major feature of HCC without any LR-M feature. Conclusions. In this retrospective single-center study in Chinese adults, iCCAs in HBV-positive patients were more likely to resemble HCCs than iCCAs in HBV-negative patients.

Elevated factor VIII levels and arterial stroke: a review of literature with a case report

Background Cerebral arterial thromboses or ischemic strokes may be caused by cumulative or independent effects of a variety of risk factors. High factor VIII level is one of those important but less known risk factors for arterial and venous thrombosis. We hereby provide a comprehensive review of the role of high factor VIII levels as a risk factor of arterial thrombosis. Moreover, we present our views on inclusion of factor VIII testing in the etiology workup protocol of young patients with ischemic strokes and their treatment with anticoagulant therapy. Case presentation We illustrate a case of 32-year-old North Indian female patient with Ischemic stroke whose only identifiable risk factor was revealed to be an elevated factor VIII level. She was treated with oral anticoagulant with an uneventful follow-up of 6 months. Conclusions Elevated factor VIII levels have their independent and additive effects in causation and prognosis of arterial strokes. We herein discuss the mechanism of this association, the feasibility and yield of routine testing, appropriate cut-off levels, and further treatment protocol especially in young stroke patients.

Incidence of Endophthalmitis, Then and Now

Purpose: Report the frequency of differing etiologies of endophthalmitis at the Upstate Medical University, and compare these results to previously reported data. Methods: A retrospective study was conducted based on the medical records of all patients diagnosed with endophthalmitis at the Upstate Medical University in Syracuse, New York between January 2014 to December 2019. Variables recorded included source of infection, microbial profiles, comorbidities, visual acuity and survival. Results: The study identified 62 patients who were diagnosed with endophthalmitis at the Upstate Medical University from January 2014 to December 2019. The most common etiology was endogenous endophthalmitis with 40 cases (64.5%), of these patients, 13 (32.5%) were culture positive. The remaining 22 cases (35.5%) were due to exogenous endophthalmitis. The mean age of patients with endogenous endophthalmitis was 51.4 years with 65.0% as male. The mean age of patients with exogenous endophthalmitis was 59.5 years with 59.1% as male. The most common identifiable risk factor associated with endogenous endophthalmitis was a history of intravenous drug use seen in 47.5%. Conclusion: Endogenous source was established as the most common etiology in patients diagnosed with endophthalmitis. These results, however, do not parallel with any of the previously reported data where endogenous etiology was identified as one of least common causes. The significance of demonstrating this increase in incidence of endogenous endophthalmitis is to illustrate a shift in paradigm and create awareness among ophthalmologists to avoid overlooking a possible life-threatening condition.

Prevalence of Hepatitis C in pregnant patients visiting a Tertiary Care Hospital in Faisalabad.

Objectives: To determine prevalence of Hepatitis C among pregnant female visiting a tertiary care hospital. Study Design: Observational study. Setting: Independent University Hospital Faisalabad. Period: 1-1-2018 to 31-12-2018. Material & Methods: Total 4210 pregnant patients visited during this time period. Results: During the study period i-e from 1-1-2018 to 31-12-2018, total 4210 obstetric patients visited Independent University Hospital. Among them 463 were Anti HCV +with % age of 10.9. Our study showed that 28 patients (6%) were <19 yrs of age, 35 patients (7%) were 20 to 25 yrs. 48 patients (10%) were 26 to 29 yrs.151 patients (32%) were 30 to 35 yrs of age. 201 patients (43%) were more than 35 yrs. Our result has shown that most of the infected patients were having their 5th or more pregnancy (202%). 182 patients (39%) were G4 or G5.47 patients (10%) were having their 2nd or 3rd pregnancy while only 32 (6%) primigravidas had this infection. Our study has shown that 325(70%) patients were of rural background while 135(29%) patients belonged to urban areas. When these Hepatitis C+ve patients were analyzed for risk factors, 91 had some dental manipulation in the past (19%), 104 had history of previous blood transfusion or some parental infusions (22%) 32 patients (6.9%) had their partners infected with Hepatitis C. 161 patients (34%) had history of some surgery or previous vaginal delivery at some centre where sterilization was not standardized. 75 patients (16%) had no identifiable risk factor. Conclusion: The prevalence of Hepatitis C is quite high in pregnant patients of Faisalabad. There is a dire need to address the factors involved in transmission of disease. Health policies should be revised to decrease the spread of this virus. Increased awareness is needed among the people regarding its transmission and early diagnosis so that curative measures should be timely taken to avoid the dreadful complications of Hepatitis C.

Brain Catastrophe presented with endocrine disruption

Pituitary Apoplexy (PA) is an acute critical endocrine condition that is infrequently encountered in daily medical practice. Its life-threatening condition that mandates prompt diagnosis and urgent treatment and may be neurosurgical intervention. Majority of cases are attributed to ischemic infarction or hemorrhage of the pituitary gland usually in the vicinity of pituitary adenoma, and in most cases could be the initial manifestation of these tumors! In reviewing the literatures there is conflicting evidence of which are the predominant, non-functional, or functional adenomas, some reports were showed that prolactin-secreting are at highest risk. There are recognizable risk factors that might precipitate this endocrine emergency like hypertension, medications, major surgery, head injury, radiation, or dynamic testing, but in majority of cases at presentation no identifiable risk factor could be detected. The typical clinical scenario includes persistent worsening headache, vomiting, and altered level of consciousness, visual defect or loss with extreme hormonal derangements which are shown by hemodynamic instability, adrenal crises with variable hormonal deficiencies.