Cardiovascular computed tomography imaging for coronary artery disease risk: plaque, flow and fat

Cardiac imaging is central to the diagnosis and risk stratification of coronary artery disease, beyond symptoms and clinical risk factors, by providing objective evidence of myocardial ischaemia and characterisation of coronary artery plaque. CT coronary angiography can detect coronary plaque with high resolution, estimate the degree of functional stenosis and characterise plaque features. However, coronary artery disease risk is also driven by biological processes, such as inflammation, that are not fully reflected by severity of stenosis, myocardial ischaemia or by coronary plaque features. New cardiac CT techniques can assess coronary artery inflammation by imaging perivascular fat, and this may represent an important step forward in identifying the ‘residual risk’ that is not detected by plaque or ischaemia imaging. Coronary artery disease risk assessment that incorporates clinical factors, plaque characteristics and perivascular inflammation offers a more comprehensive individualised approach to quantify and stratify coronary artery disease risk, with potential healthcare benefits for prevention, diagnosis and treatment recommendations. Furthermore, identifying new biomarkers of cardiovascular risk has the potential to refine early-life prevention strategies, before atherosclerosis becomes established.

Hypersensitivity to uncertainty is key feature of subjective cognitive impairment

With an increasingly ageing global population, more people are presenting with concerns about their cognitive function, but not all have an underlying neurodegenerative diagnosis. Subjective cognitive impairment (SCI) is a common condition describing self-reported deficits in cognition without objective evidence of cognitive impairment. Many individuals with SCI suffer from depression and anxiety, which have been hypothesised to account for their cognitive complaints. Despite this association between SCI and affective features, the cognitive and brain mechanisms underlying SCI are poorly understood. Here, we show that people with SCI are hypersensitive to uncertainty and that this might be a key mechanism accounting for their affective burden. Twenty-seven individuals with SCI performed an information sampling task, where they could actively gather information prior to decisions. Across different conditions, SCI participants sampled faster and obtained more information than matched controls to resolve uncertainty. Remarkably, despite their "urgent" sampling behaviour, SCI participants were able to maintain their efficiency. Hypersensitivity to uncertainty indexed by this sampling behaviour correlated with the severity of affective burden including depression and anxiety. Analysis of MRI resting functional connectivity revealed that both uncertainty hypersensitivity and affective burden were associated with stronger insular-hippocampal connectivity. These results suggest that altered uncertainty processing is a key mechanism underlying the psycho-cognitive manifestations in SCI and implicate a specific brain network target for future treatment.

The SUPERankle procedure in the treatment of foot and ankle deformities in fibular hemimelia

Objective: To review indications for limb amputation or reconstruction using the SUPERankle procedure in patients diagnosed with Paley type 3 or 4 fibular hemimelia; To evaluate the correction of deformities needed to achieve a stable plantigrade foot, review variations of the original technique and their applicability, and describe challenges encountered in their execution. Methods: Qualitative, retrospective, descriptive study of 4 patients who underwent the SUPERankle procedure between 2019 and 2020 for treatment of foot and ankle deformities in fibular hemimelia. Pre- and postoperative clinical and radiographic evaluations were performed to identify objective evidence of the correction of foot and ankle deformities. The operative techniques employed are described. Results: The included patients met anatomical and psychosocial criteria for reconstruction, as established in the literature. Clinical correction of foot and ankle deformities was achieved, but on radiographic evaluation, there was no statistical difference; this was likely due to the small number of patients, given the rarity of fibular hemimelia. Conclusion: The procedure is reproducible, but requires a knowledgeable, well-trained surgical team. Correction of foot and ankle deformities can be achieved. The choice between amputation or reconstruction should be the result of an informed decision by Family members, supported by a multidisciplinary team. Level of Evidence IV; Qualitative Study; Case Series.

Retrospective Study of Inspectors Competency in the Act of Writing GMP Inspection Report

The research was a retrospective study of twenty-five Good Manufacturing Practice (GMP) inspection reports (from March 2017 through to December 2018) of a national medicine regulatory agency, drug Inspectorate, in West Africa, designed to assess the inspectors’ expertise in the act of inspection report writing. The investigation examined a paper-based tool of thirteen pre-registration Inspection reports and twelve GMP reassessment reports written prior and following an intervention program by external GMP trainers to enhance inspectors’ skill in pharmaceutical cGMP inspection. The study made use of quantitative analysis to investigate each team’s expertise in the act of writing GMP inspection report. Likewise, each report’s compliance with the requirements of three regulatory standards on GMP inspection report writing was ascertained. Impact of intervention program on lead inspectors’ competence was assessed. Lastly, gap in each team writing effectiveness, and lead inspectors’ abilities to deliver an effective report were determined. The results showed one of the inspection team (4.0%) wrote an excellent report. Two (8.0%) of the twenty-five inspection teams penned good inspection reports. Eleven (44.0%) teams drafted needs improvement reports and the remaining eleven teams (44.0%) prepared unacceptable reports. The excellent report and the two good reports had report format that meet expectation. One (50.0%) of the good reports showed the authors possess excellent knowledge of cGMP technical areas. The remain good report (50.0%) revealed the writers’ knowledge.as good. The excellent report showed the authors displayed partial mastery in the use of objective evidence while the two good reports disclosed theirs as having partial and evolving abilities. One of the teams (50.0%) that wrote good reports displayed good use of third person narrative past tense in report writing whereas the other team used the same tense and voice excellently. Generally, a sort of marginal level of performance was prominent among the inspection teams. A gap, if not tackled, will slow down regulatory process through increase report review, litigations that query report factual accuracy (AIHO, 2017) and delay in issuance of marketing authorization. In conclusion, trainings on quality attributes, such as technical content (Quality Management System (QMS) and Site), the use of objective evidence, assignment of risk levels to GMP violations and citing of applicable laws, regulation and guidelines that substantiate GMP observations, were recommended, to enhance knowledge sharing and regulators’ performance in the act of writing inspection report.

208 Association between cardiovascular data and the development and progression of mild cognitive impairment: results from the retrospective cohort study

Aims Mild cognitive impairment (MCI) is characterized by objective evidence of cognitive impairment in one or more cognitive domains in the absence of significant interference in daily-life activities. Anyway, people with MCI are considered to be at heightened risk of further cognitive decline and progression to dementia. To date, few evidence regarding the association between cardiovascular data and MCI are present in the literature. To investigate the association between various cardiovascular data (traditional risk factors and outcomes) and the development and progression of MCI. Methods and results The study included 127 patients referred to the Neurological Unit of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan for subjective memory complaints and/or clinical suspect of cognitive impairment. Neuropsychological tests evaluating executive functions and cardiovascular data were collected at baseline and 2-year follow-up. Visit reports and medical records were reviewed to extrapolate the data. The study was conducted between 2012 and 2020. The 51 (40.2%) patients on antiplatelet therapy (94% on aspirin) had a worse baseline degree of cognitive impairment on neuropsychological tests of executive functions and had greater worsening of MCI at 2 years (Table 1). Patients on antiplatelet therapy were significantly older (75.85 vs. 71.7; P = 0.009), more ischaemic (21.6% vs. 1.3%; P < 0.001), hypertensive (90.2% vs. 60.5%; P < 0.001), and dyslipidaemic (62.7% vs. 19.7%; P < 0.001) than patients without antiplatelet therapy. No other single cardiovascular data analysed (presence of hypertension, dyslipidaemia, ischaemic heart disease, diabetes, atrial fibrillation, and anticoagulation therapy) showed a statistical significant association with MCI presence or progression. Conclusions The present study suggests that the prevalence and progression of MCI is significantly higher among patients on antiplatelet therapy, who carry a greater cardiovascular burden. Although patients on antiplatelet therapy were older, more ischaemic, hypertensive, and dyslipidaemic than patients without antiplatelet therapy, none of these parameters were associated with MCI presence and/or progression and can therefore be considered a confounding factor.

Embedding audiological screening within memory clinic care pathway for individuals at risk of cognitive decline—patient perspectives

Background With the evolving knowledge on hearing as a potentially modifiable mid-life risk factor for dementia, identification of people at risk becomes increasingly important. People with mild cognitive impairment (MCI) presenting to specialist memory services represent a key “at-risk” target population for audiological evaluation, but few services have established this pathway. This study sought to examine the patient experience and understanding of this process. Methods All patients with MCI attending a tertiary referral memory service referred for audiology review were contacted. A patient survey was delivered over the phone. Outpatient letters and the memory clinic database were reviewed. Results Twenty patients with MCI were included in the survey. Eight (8/20, 40%) had self-reported hearing loss. Upon formal audiological assessment seventeen (17/20, 85%) had objective evidence of hearing loss; nine (9/17, 52.9%) with mild-moderate and eight (8/17, 47%) with moderate-severe hearing loss. Only six patients (6/20, 30%) recalled having the rationale behind having a hearing test as part of their memory work-up explained to them. However, the majority (15/20, 75%) felt a hearing test was an important part of their memory assessment. Just seven patients overall (7/20, 35%) identified a link between hearing-loss and cognition. All patients who provided feedback on the service itself made positive comments, although (4/20, 20%) felt they did not get adequate information about the results. Conclusions A significant proportion of people with MCI had de-novo evidence of hearing impairment upon assessment. Patients are satisfied with incorporating audiological evaluation into a memory clinic assessment, however clear communication around indication, recommendations, and follow-up ensuring compliance is required.

Focused educational intervention improves intern knowledge of perioperative patient blood management principles

A perioperative patient blood management (PBM) educational intervention was implemented for first year postgraduate doctors (interns) at the Royal Brisbane and Women’s Hospital (RBWH) following identification of a perioperative PBM training requirement. This quality improvement activity evaluated the effectiveness of this educational intervention in improving intern knowledge of perioperative PBM principles.A 15-question perioperative PBM focused multiple choice questionnaire developed from information attained from comprehensive, evidence and consensus-based guidelines regarding PBM practice was distributed to interns immediately before a compulsory perioperative PBM educational intervention and then again 5 weeks later. The perioperative PBM educational intervention was delivered every 10 weeks (five interventions in total) to a different group of interns each time. Statistical analysis determined significance between mean questionnaire score before and after the intervention.The mean pre-intervention score for correctly answered questions was 7/15 (SD 2.73) and mean post-intervention score was 9/15 (SD 2.99) (p=0.02). Categorisation of questions into core domains of perioperative PBM demonstrated intern scores for correctly answered questions improved in all domains following the educational intervention.Perioperative PBM education delivered through a dedicated intervention aimed to improve knowledge is associated with objective evidence of educational benefits for interns at RBWH. It is an effective strategy to enact PBM governance and bestow clinical guideline knowledge. This is important given the global health sector’s challenge to improve patient outcomes despite increasingly restricted funding and pressure on doctors to devote more time to service and less to teaching.

Effects of Acute Alcohol Intake on Nasal Patency

Background Acute alcohol intake may influence nasal patency; however, there is lack of objective evidence. Objective The aim of this study was to evaluate the effects of acute alcohol intake on nasal patency employing both subjective and objective measures. Methods A total of 31 participants were classified into 2 groups of non-heavy drinkers (n = 17) and heavy drinkers (n = 14). Both groups consumed wine in 1 h and were assessed for subjective nasal symptoms and objective nasal patency, using rhinomanometry and acoustic rhinometry, at baseline and at 0.5, 2, and 6 h post-alcohol consumption. Results Alcohol consumption significantly increased nasal obstruction from baseline values in both heavy and non-heavy drinking groups. Total nasal volume (TNV) and the minimal cross-sectional area (MCA) were significantly decreased and nasal airway resistance (NAR) significantly increased from baseline values by 2 h post-alcohol consumption for both heavy and non-heavy drinking groups ( P < .05). Significant differences were found in TNV, MCA, and NAR between baseline and post-drinking in allergic rhinitis subjects; with no significant differences in MCA and NAR in subjects without allergic rhinitis. Pulse rate (PR) and temperature (T) were elevated, and blood pressure (BP) was decreased after alcohol consumption ( P < .05). Blood alcohol concentration (BAC) was not significantly correlated with nasal patency with regard to any subjective or objective measurement. Conclusion Acute alcohol consumption may impair nasal patency, independent of the amount consumed. Individuals with allergic rhinitis may be more prone to nasal obstruction after alcohol consumption than those without allergic rhinitis.

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies

Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.

Latent tuberculosis screening and treatment in HIV: highly acceptable in a prospective cohort study

BackgroundPeople living with HIV (PLWH) are at increased risk of reactivation of latent TB infection (LTBI). Although UK and international guidelines identify this group as a priority for LTBI screening and treatment, data on attitudes of PLWH to this policy recommendation are lacking.MethodsA five-point, Likert-style questionnaire was administered to PLWH to assess views and intentions towards accepting LTBI screening and treatment. Subsequent Immune Gamma Release Assay (IGRA) testing was offered, and chemoprophylaxis if required. Influencing demographic and psychological associations with planned, and actual, testing and treatment uptake, were assessed using multivariable logistic regression.Results444/716 (62%) patients responded. 417/437 (95.4%) expressed intention to accept LTBI testing. The only significant association was the perceived importance of testing to the individual (aOR 8.98, 95% CI 2.55–31.67). 390/393 (99·2%) accepted appropriate IGRA screening; 41/390 (10·5%) were positive. 397/431 (92.1%) expressed intention to accept chemoprophylaxis, associated with perceived importance of treatment (aOR 3.52, 95% CI 1.46–8.51), a desire to have treatment for LTBI (aOR 1.77, 95% CI 0.99–3.15), and confidence in taking treatment (aOR 3.77, 95% CI 1.84–7.72). Of those offered chemoprophylaxis, 36/37 (97·3%) accepted and 34/36 (94·4%) completed treatment. There were no correlates with actual screening acceptance.ConclusionsLTBI is common amongst PLWH, highlighting the importance of robust screening and treatment programmes. This study shows that screening and treatment for LTBI is highly acceptable to PLWH and provides strong, objective, evidence for policy-makers developing guidelines in this cohort.